Checkup nets surprise bill, but woman won’t pay

Grand Rapids

GRAND RAPIDS, Mich. (WOOD) — Fan Fan Wainer thought the $98 bill she received for her annual checkup was a mistake.

“We were just like, ‘Oh, it’s a simple error. (They’ll) correct it.’ But they just wouldn’t,” Wainer recalled.

More than a year later and after a year’s worth of phone calls back and forth with Mercy Health, Wainer received a notice from a collection agency for the $98 bill.

“I was mad. I was very mad,” Wainer said. “I don’t owe people money. I pay all my bills. But I don’t want to pay a bill I should not (have to) pay.”

Under the Affordable Care Act, most health care plans are required to provide certain preventive services free of charge. Wainer thought her yearly physical was covered.  

“It was a very regular physical check,” Wainer said of the March 2018 exam she had at Mercy Health’s Wege Center in Grand Rapids.

Mercy Health would not comment for this report, citing patient confidentiality:

“Mercy Health does not comment on specific patient cases in order to protect patient privacy. We recommend patients contact our billing department at 866-611-1512 with questions regarding their bill,” a statement read.

The Wainers say they talked to the billing department multiple times.

They said they were told the office changed the billing code for the exam because the doctor diagnosed and discussed a potential heart murmur.

“She was listening to my heart rate as one of the processes of the physical check,” Wainer recalled. “She said, ‘I heard something, have you noticed this? Has anyone talked to you before?'”

No one had, and Wainer, a healthy, athletic 45-year-old, felt fine and declined any testing. She said the doctor agreed they could wait and check it again in the future.

But an insurance industry expert with 30 years’ experience navigating health benefits told Target 8 the heart murmur diagnosis and discussion could have been enough to alter the appointment from “preventive” to “diagnostic.”

“If a condition is identified at the annual exam, you may have bills out of pocket,” explained Krista Davis of The Gremel Group in Rockford, an independent insurance agency that specializes in employee benefits. “There is a scope of services that’s considered preventive with zero cost, but if you go in and have a complaint or (a condition) diagnosed, then it changes to another category of care, and, at that point, it’s considered a copay or deductible scenario.”

Davis isn’t familiar with the Wainers’ specific case, but said their experience — and confusion — is not uncommon.

“I think sometimes there’s confusion for folks when they go in for a physical about what is considered a ‘preventive’ services and what may be other types of services the provider may render,” Davis said.

She  urged people to review their insurance plan’s list of fully covered “preventive” services before the annual physical.

She also recommended that people communicate directly with the doctor at the appointment, for instance asking, “Does (this) change what’s going to happen when I get my bill?”

It’s advice Davis first gave Target 8 when we examined this issue in 2016.

But the Wainers remain concerned, though not because it happened to them.

“It’s just so frustrating,” Wainer said. “We both have jobs so $98 probably is not a burden to us… and we can try to get our voices heard… But think about the people who have less resources. How about the people for whom $98 is one week’s groceries? How can they fight? This is not just us. It’s the principle.”

In addition, Wainer said the woman with she spoke at Mercy made it sound like she would get to the bottom of it.

“She said she understood my situation, and she understood why I was fighting. It’s the principle, not the money. So she said, ‘I will see what I can do,'” Wainer recalled. “That’s the last phone conversation I had with her. I think that was last summer.”

Then, last month, the bill from the collection agency showed up.

Target 8 also reached out to family’s insurance carrier, Blue Cross Blue Shield of Michigan, though Wainer said she didn’t blame them for Mercy Health’s decision to change the billing code. Blue Cross Blue Shield noted that it could not talk about specific patients due to confidentiality. However, the insurer does intend to look into the situation on behalf of the Wainers.  

“We would review them to determine whether there is an indication the services could have been billed as an annual preventive visit,” said Helen Stojic, spokesperson for BCBSM.

Stojic also provided the following information regarding preventive versus diagnostic services and how they are billed:

“Preventive services are part of a healthy lifestyle because they help you avoid or detect health problems. Some examples include annual health checkups, wellness screenings and immunizations.

“Health screenings and wellness exams can discover problems you may not know you have. The earlier problems are found, the greater the opportunity for treatment. Preventive services include screenings for colon and breast cancers, diabetes, blood pressure and depression. Consumers should refer to their individual benefit plan for information on coverage for preventive services.

“If you see an in-network doctor, and your visit is strictly for preventive care, you might not have to pay a copay, coinsurance or your deductible. Doctors’ offices make the determination whether to bill a service as preventive or diagnostic, so it is a good idea to talk to your doctor during the visit if you have questions.

“You may have to pay some out-of-pocket costs if:

“*You receive services other than preventive care during the same visit

“*The services are used to treat, diagnose or monitor an illness, injury or health problem”

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