Insurance-mandated medical exam? Really?
February 25, 2010 10:10 AM   Subscribe

Can a US insurance company require or request that you have a physical by a certain date?

Last April I changed jobs, and with the new employer came a new health insurance provider. My old doctor wasn't covered under my new plan, so I was automatically assigned a primary care physician. I received a letter from my insurance company notifying me that they had assigned a certain doctor as my PCP, and I could change it if I wanted but it would be this person until I did. I did nothing in response to the letter, nor did I make any plans to see this doctor.

10 months later, in February, the doctor's office called me to schedule a physical. I told them that although I had been assigned to their office by my insurance, I hadn't really given much thought to my doctor over last year, and I might want to do some research before making an appointment. They told me that I was free to go to another doctor, but "your insurance company wants you to have a physical by February 28th. So even if you go somewhere else, you need to do it by February 28th".

This sounded fishy to me, but since I figured an almost 100% covered examination couldn't hurt anything, and the "deadline" was looming, I went ahead and made the appointment with that doctor. I was seen by the doctor today, and the "physical" she gave me seemed extremely cursory and brief; I was honestly kinda disappointed. Afterward I remembered the phone call that prompted the appointment in the first place, and started wondering if I shouldn't be more suspicious about the practices of this...practice.

So, MeFites, I put it to you, could it be true that my insurance company was requiring me, or at least urging me, to have a physical by a set date?

As an aside, how extensive would a physical examination of a 27-year old American male normally be?
posted by Vorteks to Health & Fitness (10 answers total)
Call your insurance and ask.
posted by halogen at 10:11 AM on February 25, 2010

Is there a reason you can't/don't want to call your insurance company to ask whether they requested the physical? (Not being snarky, honest.)
posted by different at 10:12 AM on February 25, 2010

Response by poster: @halogen, @different - For some reason that didn't occur to me. Guess I'll do that. Still, even if they say "yes we did", I'd still want to know if that's normal practice.
posted by Vorteks at 10:21 AM on February 25, 2010

My guess is that somehow the doctor gets a monetary reward from the insurance company for conducting physicals on members that are on the HMO. My gut tells me the doctor is lying when he says, "the insurance company mandates it". Because they don't. Call member services and explain this situation.
posted by yoyoceramic at 10:32 AM on February 25, 2010

Best answer: I have never been asked or required to get a physical with employer-based health insurance.
I'm in the U.S. and have had a dozen insurance companies in 4 states.

I have been required to get a physical for life insurance.
It has also been suggested, but never required that I get a physical when switching doctors.
posted by madajb at 10:34 AM on February 25, 2010

Best answer: According to this from the Department of Labor, they CAN require a physical but they cannot use the physical to exclude you from coverage:

Can a group health plan require me to pass a physical examination before I am eligible to enroll?
No. You do not have to pass a physical exam to be eligible for enrollment. This is true for individuals who enroll when first eligible, as well as for late and special enrollees.

Can my plan require me to take a physical exam or fill out a health care questionnaire in order to enroll?
Yes, as long as it does not use individual health information to restrict enrollment or charge you more.
posted by amethysts at 10:35 AM on February 25, 2010 [1 favorite]

FWIW, my doctor's office has been on the warpath over the past few years to get me in for a physical, though they haven't yet tied it to any insurance requirement. I think it's more of an income-producing scheme on the practice's part. I mean, I've been seeing the guy for 25 years. I'm pretty sure he has a good idea of what "baseline" is for me by now.

At your young age, of course, it may be a good thing to get a physical done, to establish some sort of baseline for you in future years.

I second talking to your insurer. If, for no other reason, to see what sort of coverage you have regarding physical exams. If most of it is covered (and by "covered" I mean "paid for by the insurer" and not merely having the out-of-pocket costs applied to your deductible) why not jump at the offer? Be sure to ask about lab tests, since those are billed separate from the office visit.
posted by Thorzdad at 10:55 AM on February 25, 2010

Were you uninsured for some period of time? Often they will require a physical if you were uninsured for some length of time in the past.
posted by jckll at 11:35 AM on February 25, 2010

Response by poster: @jckll - No, I have had uninterrupted medical insurance coverage for the past 10 years.

@Thorzdad - Yeah, I figured I might as well do it. It hadn't been that long since my last physical... about 17 months. I think my last physical was in September 2008. Of course that was with a different doctor and a different insurance provider. That doctor seemed much more thorough with her examination though.

@amethysts - That is interesting. Thanks. So I suppose they could require a physical from me in my first year, although it sounds like that's not normal.
posted by Vorteks at 12:16 PM on February 25, 2010

Best answer: This is not about the actual question (no idea, sorry) but if the physical was extremely cursory and brief, I'd look for your own new doc anyway. I mention it only because I just had my intake physical for a new doctor and it was awe-inspiringly thorough and complete. I'm 33, and she went through a very long list of questions, asking about pretty much every specific region of my body, and prompting me to remember a good number of issues, past and present, that I'd never have thought to mention without the specific questioning. It took probably an hour, just talking to the doctor about stuff.
posted by rusty at 1:54 PM on February 25, 2010

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