Wellness Visits and insurance: what’s included?

Since the Affordable Care Act, insurances are required to include certain preventive services in their policies. (Policies, that is, that are not grandfathered in.) This is definitely a step forward, as it means that patients do not need to pay for a visit that focuses on preventing illnesses (or catching them early).

However, what patients are not often aware of is that these visits are meant to be just that – preventive care. Preventive care, in the insurance company definition, means “anything that hasn’t produced symptoms yet.” If it’s produced symptoms, then any workup and testing becomes diagnostic. So what happens if you are having symptoms and want to address those in the preventive patient visit? Then your insurance company may not cover for that portion of the visit, and you may face a bill. This is also true for any labs and tests. If the lab or test is to workup any symptoms that the patient is having, the insurance company will regard it as diagnostic – not preventive.

(There is a lot more than I cover here about preventive services – in the  case of one insurance company guideline, nearly 70 pages worth. Suffice it to say that if you have a screening test done and problems are found, the insurance company will pay for it as a preventive service. But you should talk to your insurance company ahead of time if you have questions about what will or will not be covered.)

This can be confusing not only for patients, but for healthcare providers as well. And it is different than what was the norm in the past. In the past, if someone came in for an annual exam, we would use that time to go over any problems the patient was having and work those problems up. We still do so, but  we now have to explain to patients that that portion of the visit will not be covered under the “free annual exam” by the insurance company. Please understand that this is as frustrating for your provider as it is for you.

So what should you do when preparing for your annual preventive screening? First, call your insurance company, and find out what is covered. As well you probably can go to the insurance company’s website, create an account, and access benefit descriptions.

The key is to understand that while you should mention symptoms you are having (and we will ask if you are having any symptoms, obviously, no healthcare provider is going to stop doing that), actually working up those symptoms can’t be included as part of the free preventive screening. “Working up” includes not only taking extensive history of a symptom, but asking questions about it (diagnosing), as well as any testing done to assess what it is.  So depending on how urgent the situation is, we will either go over it is a separate part of of the visit, or schedule a further visit to focus on those symptoms and problems. The ‘working up’ part of the visit will need to be billed separately to the insurance company, and it will not be part of the free visit.

Also, you may want to know that your insurance company may limit preventive services to those that meet certain criteria. One criteria is that it be a “Grade A or B” service. This usually refers to guidelines published by the United States Preventive Services Task Force (USPSTF). The USPSTF is a group that reviews various tests and screening and looks at the research done on the outcomes of those studies. The take home is they ask “Does actually performing this test or screening service reduce the problems it is supposed to reduce, in the population at large?” If the answer is no, then they tend to recommend against that test or screening service.

Now, many healthcare providers of whatever type do not always agree with these recommendations, which have included not performing mammograms on women under age 50 and over age 40, for instance. And the guidelines are meant to be guidelines – not hard and fast rules. But what this does mean in practice is that many procedures that you may have heard about, including specialized screening tests, will not be covered by your insurance company. Or “not covered” if you do not fall into certain high-risk groups. So if you want to get those tests, you will need to be prepared to pay for them out of pocket. And if your insurance company decides that they are not “medically necessary”, you may want to find out if the cost of those tests will be applied to your deductible or not.

So, given all this, what will you get from the preventive care visit? Well, one thing you will get – that is very worthwhile – is a chance to have a visit that is focused on helping you prevent problems before they become symptoms. Instead of “putting out fires”, we can focus on keeping the fires from getting started. If this if the first time you are seeing your provider, this is a great time for them to get to know about all those background factors that don’t always get covered thoroughly in “sick visits”. Your dad’s family history of heart disease, or mom’s family history of diabetes, the fact that you’ve been anxious since childhood, your diet, your exercise (or lack of exercise) – this is a good time to go over those things. If you’ve been seeing your provider for awhile, it can be a good time to talk about those aspects of your healthcare. And if you are seeing a provider where you  go over those things anyway at visits – consider it a good time to see where you have come from, and what your goals are, health-wise.