How Much Will Your Annual Well Check Cost?

By pokitdok,

Who would have imagined 5 years ago that a visit to the doctor could result in such a headache? But that’s exactly the predicament faced by most of us when figuring out how much a doctor is going to charge for a preventative care visit.

Doctor examining a patient

We may worry about our high deductible, or the ever-growing cost of a co-pay, but luckily in a post Affordable Care Act world, we can at least take a deep breath and set our worries aside when it comes to preventative visits (other issues aside).

As of September 2010, the Affordable Care Act instituted a new requirement: members of an individual, small group, large group, or self-insured health plan, using an in-network doctor, cannot be charged a co-pay, coinsurance, or be held accountable for meeting a yearly deductible for preventative services. There is an exception to those plans that hold a “grandfather status.”

The grandfather status plans offer an additional list of preventative services, allowing for screenings such as high blood pressure, high cholesterol, colorectal cancer, type 2 diabetes, HIV, and certain immunizations (i.e. hepatitis, herpes, influenza).

But what may be surprising is that the designation of preventative includes a longer list meant to fully protect members' health. In general, screenings for abdominal aortic aneurysm, alcohol abuse, depression, obesity, syphilis, and tobacco use are allowed.

For women, this list expands even further to include screenings for anemia, breast cancer, cervical cancer, chlamydia, domestic violence, gestational diabetes, gonorrhea, human papillomavirus (HPV), osteoporosis, rH incompatibility, and urinary tract infections (UTI).

Additional coverages include counseling services for alcohol abuse, diet, obesity, breast cancer chemotherapy, breastfeeding, domestic violence, and sexually transmitted infection prevention.

What about supplements or certain medications? What about a full medical history of children? The Affordable Care Act has those covered as well. No co-pay, no co-insurance, no yearly deductible requirements.

So, “What’s the catch?” The catch is that preventative visits can easily turn into medical procedures.

Some examples include:

A doctor finds a wax build-up during an ear exam, and recommends an irrigation. Without thinking, the patient agrees. The routine exam has just turned into a medical procedure, and is not covered.

A dermatologist finds a mole during a routine skin exam, and recommends that it be removed. While the exam is covered, the removal of the mole is considered a medical procedure, and is not covered.

A patient visits the ophthalmologist for an eye exam because of diabetes and wants to see if there are any complications. Unless the patient tells the doctor the visit is for preventative care, it will be billed as a medical procedure because the doctor was specifically looking for complications associated with diabetes.

It can be hard to make these evaluations when sitting on a cold, hard, steel table, dressed in a thin sheet of white paper, so it's important to understand what each insurance policy covers prior to preventative care visits.  Asking questions and confirming the purpose of each visit with the doctor will help reduce confusion and allow patients to set up subsequent appointments for any needed procedures–and perhaps, even shopping around for the best value.

The opinions expressed in this blog are of the authors and not of PokitDok's. The posts on this blog are for information only, and are not intended to substitute for a doctor-patient or other healthcare professional-patient relationship nor do they constitute medical or healthcare advice.

  Tags: Healthcare consumerism


  Comments: 2

  1. Mary Pat Whaley

    Great information!

    What further complicates things for senior patients is that Medicare is not subject to the ACA requirements and the preventive care visits (Welcome to Medicare, Annual Wellness, Subsequent Wellness Visits) do NOT include any physical exam at all.

    Patients need to be armed with information, and the physician practice must often provide education to patients about how their insurance works. Although not a popular concept, I believe the exam room is the place where the conversation about out-of-pocket expenses needs to happen.

Your feedback