Recently, two of the Healthcare Hustlers’ friends had the same experience - they saw their doctor for their FREE annual physical, then got a bill that they had to pay for the lab work.
Unfortunately this is a common occurrence and can prove stressful and costly. We broke down some dos and don’ts to follow when going in for your annual physical. Before we get into the deets, we want to make sure you understand two key terms first:
Preventive Care: Care that is designed to prevent illness or detect problems before you notice any symptoms.
Diagnostic Care: Care to treat a known problem, or to diagnose a suspected problem because of known symptoms or abnormal test results.
Now that you understand the key differences between preventive and diagnostic care, follow these three easy steps to help avoid costly medical bills during your annual physical.
STEP 1: UNDERSTAND WHICH TESTS CAN BE CONSIDERED PREVENTIVE BASED ON SEX AND AGE.
Doctors often order tests that are not considered preventive, such as Vitamin D and thyroid function testing. Coming to your visit armed with a list and reviewing with your doctor ensures they are not adding on extra tests.
These two links are helpful guides for understanding which preventive tests you qualify for.
You should also check your insurance’s specific guide - below are a few examples. Note: These are subject to change.
STEP 2: BE CLEAR WITH YOUR DOCTOR THAT YOU ARE ONLY THERE FOR A PREVENTIVE ANNUAL PHYSICAL, AND EVERYTHING SHOULD BE CODED AS “PREVENTIVE”.
Under the ACA, annual physicals with in-network providers are free to the patient, as they are billed with unique “preventive” codes. However, if you are at your physical and start to tell the doctor about your sore throat, your aching knee, or your fatigue, this changes the coding from preventive to diagnostic as the doctor is now diagnosing your ailments.
Set expectations with the scheduler, the front desk, the medical assistant/nurse, and the doctor that you are there for an annual physical. If you aren’t sure if something will change the coding of the visit, ask the following: “Does talking about this condition today change my visit from preventive to diagnostic?” Most doctors will be able to give you an answer. If they say yes, ask them to set up a separate visit to discuss these concerns.
This applies to labs in the same way. The idea of preventive lab screenings is that the doctor is screening for something that you aren’t already diagnosed with or seeing symptoms for. If you have a documented and known condition (such as diabetes), the doctor cannot run a preventive glucose test for diabetes. If you express concern about several symptoms commonly associated with heart disease, your cholesterol test (included in the lipid panel) will not be billed as preventive.
STEP 3: ENSURE YOUR DOCTOR IS SENDING YOUR SAMPLE TO AN IN-NETWORK LAB.
Ask your physician where they send the samples, and check on your insurance provider’s website to see if that lab group is in-network. Oftentimes, they will send your sample offsite to Labcorp, Quest, or another national lab, which bills under a different tax ID. If they are out of network (even if your doctor is in-network), you may end up footing the bill.
Preventive Care Services By Insurance Company
As mentioned above, coverage varies based on the insurance company. Below are links to the preventive services page for some of the largest insurance companies in the country, along with the Healthcare.gov guidelines.
Lastly, don’t forget to review your EOB after the visit!
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