Avoid Insurance Surprises: Know What’s Covered in a Wellness Visit

A doctor and patient in annual visitWellness visits, also called physicals or checkups, are an important part of staying healthy. They provide a time for you and your primary care doctor to focus on preventive care and lifestyle habits, such as diet and exercise, that can impact your overall health. Most insurance policies fully cover the cost of an annual wellness visit.

However, what happens if you start asking the doctor about new symptoms you may be experiencing?

More Time and Services Mean Different Billing

Here is a guide to the steps that may lead to a bill or co-pay for your wellness visit.

  • If you bring up new symptoms, such as indigestion or aching joints, at your wellness visit, the doctor will need to make notes about the conversation and spend additional time with you to explore the symptoms, any needed testing, and possible treatment.
  • This, in turn, may trigger rules that require your doctor’s office to code your visit for billing and insurance purposes in a different way.
  • Even if your insurance company fully covers an annual wellness visit or physical, you will still be responsible for part of the bill in this situation because you are receiving more than just preventive services.
  • Likewise, if you need to discuss management of an ongoing health problem that’s already been diagnosed, such as diabetes or high blood pressure, this will also lead to different billing.
It’s Like Home Repair Versus Home Maintenance

A good analogy to this situation is the maintenance and repair of your house. You may schedule someone to do an annual furnace inspection to make sure it’s running safely and ready for the winter weather. However, once they arrive for the maintenance visit, if you ask them to also figure out why the furnace is making a strange noise, they will need to spend more time looking at the furnace and possibly need to repair something.

Your primary care doctor wants to hear all of your health concerns; just keep in mind this may add time and services to your wellness visit and result in your insurance not fully covering your visit.

What Is Covered in Well Visits and Sick Visits?

The following explanations outline what is typically covered in each type of visit. However, you should always consult with your insurance company for specific information about what your plan covers.

  • Well Visit

    A wellness visit, also called an annual physical or checkup, includes the following:

    • Reviewing vaccinations
    • Talking about diet and exercise or other lifestyle habits that may influence your health
    • Discussing any routine screening tests that are recommended for your age, gender, or health history
    • Reviewing your current medications
    • A general examination of your vital signs, breathing, reflexes, skin, thyroid, and examination of your ears, nose, and throat
  • Sick or Chronic Condition Visits

    This is a visit for new symptoms or complaints, or a follow-up on chronic problems, such as diabetes, cholesterol, blood pressure, etc.

  • Sick/Chronic Condition and Well Visit

    This is a combination of a sick or chronic condition visit and a well visit. If you scheduled your annual exam, but then wanted the doctor to talk to you about a new blood pressure medication for your ongoing high blood pressure, then you would be billed for a combination visit. With this type of visit, you will be billed for co-pays and deductibles.

Need to Schedule a Visit? Communicate When You Call

If it’s time to schedule a visit with the doctor, be sure and tell the receptionist everything you want to cover in your visit so they know how much time to set aside. It will also allow them to tell you ahead of time if your goals for the visit are considered a sick visit or a wellness visit.

If you’re looking for a primary care doctor, LeBauer HealthCare offers primary care services in seven locations throughout the Triad. Use our convenient online form to schedule your visit, or call the office nearest you.

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