Why you get two bills for one visit

Patient alert: If you’re going to your doctor for a checkup and expect it to be covered 100 percent by your insurance company, think again.

You could be charged for an extra “office visit” if you ask questions about existing medical problems, such as high blood pressure or cholesterol.

It happened tomein 2012 whenI sawmyfamily doctor for an every- other- year checkup. My insurance paid $ 256, the total for the preventive exam. But the explanation of benefits showed that I also owed $ 74.60, my share of the $ 113 bill for an “office visit” — on the same day, in the same time slot.

Puzzled, I called my doctor, Dael Waxman at Elizabeth Family Medicine in Charlotte, N. C. He explained the second charge resulted from our talk about my elevated cholesterol level, which had been diagnosed previously. Because he documented that discussion and marked the billing code for evaluation and management of a cholesterol diagnosis, I was billed for the second visit.

I objected, believing that I should have been able to talk about cholesterol at a preventive exam. Waxman pretty much agreed. And because I hadn’t been made aware in advance of the second charge, he deleted it frommy bill.

I have learned since that it’s not unusual to get this extra charge with a preventive exam.

In the past year or so, primary care doctors say they have struggled over how to manage their time during preventive visits whenpatientsbringupquestions about chronic medical problems. Ifthediscussion in a preventive exam turns to previously diagnosed conditions, the code for that signals the insurance company to pay for an “office visit,” which usually means a copayment fromthe patient.

“It’s very confusing, even for the doctors,” said Dr. Dino Kanelos of Carolina Family Healthcare in Charlotte. “I just finished ( a preventive exam) with a lady who had 15 medical problems shewanted to discuss.”

There are multiple factors atworkhere. This practice of billingforanextravisitbegan before the Affordable Care Act’s insurance mandate took effect Jan. 1. But some doctors and insurance companies may be using this opportunity to more strictly followguidelines aboutwhat qualifies asapreventiveservice under the act, and must becovered100percent without patient cost- sharing.

In addition, doctors are under pressure to document everything appropriately in the electronic medical record or they could be subject to Medicare reimbursement cuts in the future. That takes more time, so they have less time to handle extra questions from patients. And with the growing prevalence of high- deductible insurance policies, patients may save their questions for the preventive exam, hoping they can avoid paying the full cost of a separate medical visit.

“It’s a Catch- 22,” Kanelos said. “Iwant to be able to say, ‘ What’s going on? Is there anything wrong with you?’ Intheolddays, that’stheway I picked up a lot of problems. ... Now, it is hard to figure out what to do.”

Because this is confusing to patients, some doctors have begun sending notices in advance, letting patients know they could be charged extra if they bring up questions that aren’t considered part of a preventive exam.

Kanelos’ patients not only get an email in advance, but on the day they arrive, they’re asked to initial items on a second document. Here are two of the choices:

I choose to have only the services performed that are included in the basic preventive exam.

I acknowledge that I may ask my provider to evaluate and manage my medical problem( s) during my preventive exam and that this treatment will result in a separate office visit to be billed in addition to the preventive exam.

In Mount Holly, N. C., Riverbend Family Practice also has begun sending a two- page form to patients in advance of preventive exams:“Thisvisitisdesignedto educate you on changes you can make to live a healthier life and to identify new health problems. This office visit is NOT designed to address specific complaints or tomanageknownmedical issues.”

The notice explains that a preventive exam covers a review of immunizations, habits such as smoking and exercise, diet, and screening tests for colon cancer, breast cancer and diabetes. But it also says a preventive exam covers“pastmedicalhistory” and “interim medical history since your last physical exam.”

Some doctors blame companies.

Colleen Dey, Kanelos’ officeadministrator, said insurers seem to have strictly adopted the list ofpreventive services outlined in the Affordable CareAct.

“They seem to be saying, ‘ We’re required by law to cover these tests, so that’s all we’re going to do,’ ” Deysaid.

But insurers say it’s up to physicians to decide which codes to apply for billing purposes.

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