ACA coverage for bloodwork on an annual wellness exam?
January 13, 2015 11:29 AM   Subscribe

I'm waiting for a response back from the billing department of my physician, but I am curious about whether they are in compliance with the ACA and whether I should be looking for a new doctor.

I recently moved and switched jobs and insurances (I have an HDHP now) and decided to find a new in-network physician. I made a new patient appointment for an annual wellness visit (I am 34 years old). Now I have a bill for the following services performed: Blood Draw, General Health Panel, Lipid Panel. I thought the ACA covered an annual wellness visit in full? Is this charge legit?

Further, if these services are not covered by an annual wellness visit, then that should have been disclosed to me at some point, right? Or is it my responsibility to ask at every point in a doctor's visit whether or not my insurance covers each specific procedure? Do I just need to find a new doctor's office, or do I need to be more pro-active with my current doctor? I liked the office just fine during my visit, but this was my first appointment. Thus, I don't mind looking for a new doctor. Is it typical not to have such costs explained prior to the services? Would I even have luck with another doctor?
posted by cnanderson to Health & Fitness (18 answers total) 3 users marked this as a favorite
How much is the bill? I had similar tests done recently at LabCorp and the contracted/negotiated price was $29. I don't mean my co-pay was $29, but rather that the total bill after discounts was $29. The charges with your insurance and having the tests performed in-office may be different, but it shouldn't be very much.

Here's what a random insurance company says is 100% covered for preventative care. Routine bloodwork is not included.

For the most part, in my experience, this is pretty much how American medicine works. I doubt another doctor would be any different.
posted by zachlipton at 11:40 AM on January 13, 2015

This will be up to your insurance, not to the doctor's office, so changing doctors wouldn't help.

The ACA does mandate coverage for the annual wellness visit, but the blood work (which is what the draw and two panels are) may or may not be covered, depending on your insurance plan.

It's generally up to you, not the doctor's office, to investigate what your insurance will and will not cover - they don't even know for certain what's covered until they submit the claim after you've already been to the office.
posted by okayokayigive at 11:54 AM on January 13, 2015

Is this charge legit?
Depends on what your insurance plan's definition of preventive care is and what billing code it was submitted under. I have an HDHP and my Summary Plan Description states that the 100% coverage for preventive care "Includes coverage of additional services, such as urinalysis, EKG, and other laboratory tests, supplementing the standard Preventive Care benefit." Preventive Care is defined by reference to, which provides this list. You'll need to look at your plan's documentation.

Is it typical not to have such costs explained prior to the services?
Yes, unfortunately.

Would I even have luck with another doctor?
Probably not.

I'd ask the billing department if there is another code they can submit the charges under so that they're covered by the ACA/your-insurance-specific preventive care benefit.
posted by melissasaurus at 12:05 PM on January 13, 2015

There are so many different insurance plans out there. Most doctors' offices post a disclaimer somewhere saying they are not responsible for knowing what your specific plan covers.
posted by treehorn+bunny at 12:08 PM on January 13, 2015 [1 favorite]

Response by poster: I'll try not to threadsit, I promise, but by asking for an "annual wellness visit", I thought I was asking for what was covered by my insurance as mandated by the ACA. I did not know at any point during the visit when the activities stopped being a "wellness visit" and stuff I'm charged $150 for. In the grand scheme of things, it's not that bad of a bill, but it really sucks that (even while healthy) I can't know the costs of services until they are already performed. If I knew the costs, then I could shop around. I mean, even my auto repair guy has me sign a quote before going ahead.
posted by cnanderson at 12:08 PM on January 13, 2015 [1 favorite]

I would suggest calling your insurance plan to go over this; do you know if they have fully processed the claim? Perhaps the bill from the lab or office does not include payments still outstanding from your insurer.
posted by ThePinkSuperhero at 12:16 PM on January 13, 2015 [1 favorite]

I have had the same thing, although my bill was something less than $150. It was the first time I've had to pay anything for routine blood work performed in a Wellness check. I was a little annoyed at not being told I'd have to pay for it.
posted by feste at 12:22 PM on January 13, 2015

If your insurance is like mine, they encourage the bloodwork as part of a program to charge you less for insurance next year. As in, did you get your bloodwork done? Check. Did you quit smoking? Check. Did you have an eye exam? Check. Ok, you don't get charged extra for insurance next year.

I had to pay for my bloodwork, but in the bigger scheme, the bloodwork cost less than the difference in insurance fees if I didn't get it done.

Next year, on the paperwork you have to fill out and send to the insurance that has your bloodwork results, I believe you could have your doctor exempt you from the actual tests and you could still qualify for the lower insurance rate.
posted by jillithd at 12:23 PM on January 13, 2015

Generally whether or not this is going to be payed by you vs. your insurance is determined by your insurance plan, not by the doctor. So I don't think seeing someone new would help in that sense. For what it's worth, when I had similar blood tests done this past year, it was not free either (although it was also not $150...I believe mine was partially covered so it worked out to perhaps $25).

One thing you could do is to call the doctor and clarify how it was billed/whether it's possible to resubmit to the insurance company under a different code that might be more likely to be covered. Doesn't hurt to ask. Some offices are better about this type of thing than others.
posted by rainbowbrite at 12:28 PM on January 13, 2015

I did not know at any point during the visit when the activities stopped being a "wellness visit" and stuff I'm charged $150 for. ... it really sucks that (even while healthy) I can't know the costs of services until they are already performed. If I knew the costs, then I could shop around. I mean, even my auto repair guy has me sign a quote before going ahead.

As people have said, your doctor can't know what your insurance company covers. Your doctor has dozens, if not hundreds, of patients all on completely different insurance plans.

Many plans would cover the bloodwork under the umbrella of a wellness visit; many plans would Not. The shopping around you want to do needs to happen at the point of *purchasing insurance,* not at the doctor's visit. You can indeed know what things will cost but the people you have to ask are your insurers.

Yes, it sucks that it's completely on you to prevent and/or resolve unpleasant surprises. The US healthcare system sucks, a lot.
posted by We put our faith in Blast Hardcheese at 12:30 PM on January 13, 2015

You might find out if you had taken an order for bloodwork to be done at a lab (something like Quest Diagnostics) if the charge to you would have been the same. Just like insurance companies have preferred in-network doctors, they have in-network blood labs as well.
posted by cecic at 12:40 PM on January 13, 2015

Response by poster: As people have said, your doctor can't know what your insurance company covers. Your doctor has dozens, if not hundreds, of patients all on completely different insurance plans.

Yes, but all of these plans must cover a "wellness visit" as mandated by federal law. There still is a communication breakdown if my interaction goes something like this:

Insurance company to me: Go get an annual "wellness visit", it's covered at 100% if you go to an in-network doctor!
Me to in-network doctor's office: I'd like one "wellness visit", please.
In-network doctor's office to me: Here's your "wellness visit", now pay me $150. Welcome to the practice!
Me to insurance company: In-network doctor is charging me $150, I thought this was fully covered?
Insurance company to me: No, you had a wellness visit and non-covered medical expenses, we don't owe that money, you do.
Me: :( Maybe I won't go to the doctor next year? I think I feel fine.
My wife to me: Just pay the bill and go to the doctor, and you are still getting your cholesterol checked yearly.

My health insurance coverage is provided through my employer, but maybe I should shop around. Thanks all for your feedback!
posted by cnanderson at 1:07 PM on January 13, 2015 [1 favorite]

blood work, radiology, etc., stemming from an annual wellness exam is NOT covered implicitly by the ACA. your insurance may be awesome and cover such things, but it is not because the ACA told them to.

and yes, it is your responsibility to know what your insurance does and does not cover. your doctor has no clue at all. his billing staff probably does, but they're not in the exam room with you.

the papers that came with your insurance card (it will also be online) will explicitly say what is and is not covered. pap smears, mamograms after X age, prostage exams after X age, those are all covered for free as wellness. your paperwork will say what your copay and coinsurance is for everything else, including labwork.
posted by misanthropicsarah at 1:11 PM on January 13, 2015

Best answer: Certain tests may be covered as part of the ACA preventive care mandate or they may be covered as part of extended preventive care benefits offered by your insurance plan. For example, a cholesterol screening is covered under ACA for all men 35 and over and men and women 20 and over with certain risk factors. If you are not male and over 35, having it covered by your insurance may be as simple as your doctor re-billing it under the code for "cholesterol screening; risk factors" rather than "cholesterol screening" (or whatever -- I know nothing about the actual codes).

I'd call your insurance and see what CPT codes are included in your preventive care benefits. Then, make sure that whatever service you're receiving will be billed under one of those codes.
posted by melissasaurus at 1:27 PM on January 13, 2015

Your understanding of the system is pretty much accurate. There are many communications breakdowns. These are, by and large, not viewed as problems by the industry (or at a minimum, not viewed as solvable problems).

While misanthropicsarah is right that you'll have paperwork from your insurance company, this stuff is not remotely obvious and the actual dollar amounts are opaque until the bills actually come back.

I'd probably just pay it, but the only thing I might push back on is the amount of $150. Was this an in-network contracted price after billing your insurance?
posted by zachlipton at 1:36 PM on January 13, 2015

Given that chain of events, I totally understand why you are annoyed. If you liked this doctor, I would stick with him as it's more a fault of the system than of him individually. If you were meh, there's no reason not to try someone else. Either way, next year I'd call your insurance company or check their website ahead of time, see what specifically is covered under the wellness visit, and then clarify with the scheduler when you make your appointment. Then, if your doctor recommends tests beyond that, you can make an informed decision of whether you want those tests or not, talk to him about how necessary they are, etc. (Personally, I'd want my cholestorol checked whether it was covered or not, but YMMV depending on your budget, risk factors, etc. And, at least it won't be a total shock.)
posted by rainbowbrite at 1:41 PM on January 13, 2015 [1 favorite]

One thing you can do is to ask the billing person or receptionist what percentage of their patients have the same insurance provider as yours, and pick one who is very familiar with your carrier. Providers who have a high percentage of patients with your same insurance company have already figured out how to get the highest payment possible from the insurance company. At least they are less likely to be learning with your claims.
posted by summerstorm at 1:44 PM on January 13, 2015 [1 favorite]

The issue you're having is that a "wellness visit" is not a single well-defined package of services. The ACA has certain mandates, which insurance companies interpret in certain ways and may augment with additional coverage. For example, the ACA may mandate coverage of cholesterol checks for anyone above a certain age with certain risk factors, but your particular insurance plan may cover it for you even if you don't meet the ACA requirement because they're decided it's worth it to do so.

Basically, what you think a "wellness visit" means, what your doctor thinks it means, what your insurance company thinks it means, and what the ACA thinks it means are all different, and unfortunately it's ultimately your responsibility to figure out what's in the middle of the Venn diagram.
posted by MadamM at 7:18 PM on January 13, 2015 [1 favorite]

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