I recently had my regular annual check-up with my doctor.  I really didn’t have much wrong, but I wanted to talk to her about a few issues I was having.  The nurse quickly told me that if I had to talk to the doctor about a specific “problem,” the office could not do my annual check-up at the same time since my insurance plan would only pay for the annual visit as “preventive” if I didn’t talk to the doctor about any specific issues.  

That seems silly, doesn’t it?  But the nurse is right!

This isn’t the doctor’s rule but rather an insurance rule.  Your insurance will normally cover a “preventive” visit once a year.  This “preventive” visit is to check your blood pressure, weight, and other general indicators of how healthy you are.  If you’re a woman, you may get your annual pap smear and mammogram.  If you are a man, you may get your prostate checked along with a colonoscopy.  These “preventive” visits are different than an appointment you make to see the doctor for a specific problem.  If you have a problem, the doctor will bill your insurance as a regular visit.  If you have a co-pay, you will have to pay out-of-pocket for a portion of the visit.  The amount that you pay will depend on your insurance plan.

It’s important to understand this because the doctor can’t just mark down the visit as “preventive” if it’s not.  Many patients call the doctor’s office after the visit to say they want the billing for the visit or service changed to “preventive” so the insurance company will pay for the entire visit or service.  The doctor can’t do this.  If they do change the billing, they are committing “fraud” and can get in trouble.

The best way to handle how you are charged is to call your insurance company beforehand and ask what preventive services are fully paid for by the insurance company.  You can ask your doctor; however, there are a lot of different insurance plans and the doctor’s office might not have the right answer for your plan.

Tell us how you  make sure you know what’s covered for you and your family under preventive services. We’d love to hear from you!

For more information about your health insurance, see HealthSpin’s Easy Healthcare: Choosing Your Health Insurance.

We hope we’re helping you “Spin Your Healthcare Your Way!