Why your ‘free’ yearly checkup might still cost you

Target 8

GRAND RAPID, Mich. (WOOD) — Eight months after patients shared their frustration over being billed for annual checkups, major health care providers in West Michigan told Target 8 they’re working toward more transparency.

But one patient is skeptical.

“The consumer doesn’t have a voice,” said a man who recently reached out to Target 8 with questions about how yearly exams are billed. “To me, it must be about the bottom line. They’re double dipping,” he continued, referring to providers who charge patients for services provided during checkups.

Under the Affordable Care Act, insurers are required to cover annual “preventive” care. However, there are limits. West Michigan’s biggest health care institutions are trying to help patients better understand those limits.

Among other efforts, Spectrum Health places a brochure explaining annual wellness visit coverage in waiting and exam rooms at doctors’ offices. The pamphlet lists examples of symptoms that might incur additional charges if discussed or treated during a routine physical. The list includes abdominal pain, fatigue, irregular periods, joint pain, new cough, new or changed headache pattern, pelvic pain, sinus infection, sleep problems and sore throat.

Spectrum Health is currently working to revise the brochure to make it clearer based on consumer feedback.   

“It’s complex, obviously,” said Amy Assenmacher, a vice president of finance for Spectrum Health. “(It’s) a challenge for all health care systems industry wide because there are guidelines provided by the American Medical Association, coding guidelines.”

Assenmacher sat down with Target 8 to talk about what Spectrum Health is doing to help patients understand when they might incur an additional charge during a routine checkup.

“So, let’s say a patient comes in for their annual wellness visit and wants to talk about some joint pain or severe abdominal pain, which isn’t considered preventative, and that may require additional services or an intervention or surgical procedure,” Assenmacher explained. “That does kind of fall outside of the typical topics or conditions that would be covered in an annual wellness visit or physical.”

Assenmacher provided the examples as reasons a patient might incur an additional charge during a routine, “covered” visit.

PATIENT: $83 FOR 30 SECONDS

But the consumer who contacted Target 8 said he was charged $83.12 for having a brief conversation with his doctor about some bowel irritation he’d been experiencing.

The man did not want to identify himself for fear he wouldn’t be able to find a new doctor. He also did not name the health care provider that billed him for the checkup.  

He explained that he had gone for his yearly physical and briefly mentioned that he thought he might be having stress-related irritable bowel syndrome.

“My doctor said, ‘Yep, it’s probably stress, but I would also lay off the dairy,’ and that was the extent of our conversation,” he explained.

But the discussion he thought took less than 30 seconds ended up costing him 83 bucks.

“A couple of weeks later I get an additional bill. I called them up, and they said, ‘Well, you talked about a new symptom that you haven’t had before and that is considered another office visit,’” the consumer said.

He explained that the bill has made him reluctant to have open dialogue with his doctor.

“It was incredibly annoying. I think I’m going there to have a conversation with my doctor and be proactive about any issues that might come up only to find out that as I’m sitting there, every word I say might lead to my being charged,” he told Target 8.  

SPECTRUM HEALTH’S CHECKUP SCRIPT

Assenmacher said she understood consumers’ frustration.

“I do. I do. And I think that’s where the obligation is on every health care system to have that conversation with a patient as early as possible,” she said.

To that end, Spectrum Health now instructs its appointment schedulers to share a statement to patients who call to set up annual checkups.

“A complete physical is considered a preventive visit,” reads the script provided to Spectrum schedulers. “Discussing a new or unstable chronic condition is not covered as part of the annual physical and may result in additional charges.”

Assenmacher acknowledged that just discussing a new symptom during a yearly checkup, even if there’s no specific treatment required, could cost the patient.

“The (federal) Office of Inspector General expects us to submit an accurate and compliant claim. So, when a physician provides a service or has a conversation, there are guidelines that ensure we are documenting, coding and billing correctly,” Assenmacher explained.

BILLING CAN BE CONFUSING FOR DOCTORS, TOO

In order to get reimbursed by insurers, physicians must submit billing codes that correspond with services provided.

According to the Current Procedural Terminology coding manual, created by the American Medical Association, if a physician provides a “significant, separately identifiable evaluation and management service” during an annual exam, it should be coded separately from the preventive wellness visit.

It’s that additional coded service that costs the patient.   

“The (coding standards) are subject to interpretation, but there are standards put out by the American Medical Association to stipulate what those conditions are and how they are to be documented and billed appropriately,” Assenmacher said.

While Assenmacher acknowledged that the guidelines are subject to some interpretation, a Mercy Health administrator went even further.

“If you were to ask 10 doctors their opinion on when (an annual exam) flips to a ‘problem-focused visit’ that’s associated with a patient cost, you’ll probably get five or six different answers,” said Dr. Kristen Brown, president of Mercy Health Physician Partners. “It’s a problem. It indicates to me that the rules aren’t clear and there’s a lot of confusion.” 

Brown said physicians are as frustrated as patients by a health care billing system with countless benefit plans and insurance carriers, private and governmental.

“Because there is some leeway (in billing for annual exams), doctors aren’t always clear on what the cutoff is either,” Brown explained. “It’s fraudulent for doctors to not charge for the work they’re doing or to overcharge, and with the government and payors really looking at and scanning documentation and billing codes and clamping down on it to make sure providers are doing it right, a lot of providers are nervous about the appropriate level to bill as well.”

WHAT LOCAL HOSPITALS ARE DOING ABOUT IT

Mercy Health, like Spectrum Health, is working to communicate earlier and more often with annual wellness patients regarding when they might incur additional charges.

Both health care systems, in addition to requiring appointment schedulers to advise patients regarding annual exam billing, are encouraging registration clerks, office staff and physicians themselves to talk openly with patients about billing. 

Spectrum Health said Target 8’s initial story in May 2019 prompted the system to accelerate efforts of a system-wide work group focused on increasing patient understanding of common misconceptions regarding billing, including that for annual exams.

Metro Health is also working to increase patient awareness of billing practices for routine checkups.

“We are currently examining our annual wellness exam process and creating the best experience for our patients,” wrote Jamie Allen, Metro Health spokesperson, in an email to Target 8. “We are committed to meeting our patients’ requests while being as transparent as possible before their annual visit.”

Health care providers urge patients to ask questions regarding annual exam billing when they call to schedule their appointment, arrive at the office the day of the visit and, if they’re still concerned, during the exam itself.

“We want doctors to be able and comfortable to have that conversation with patients if they know that they’re discussing something that is above and beyond what the annual wellness visit purpose is,” Assenmacher explained. “Our focus is on the patient and making sure that they’re staying healthy. That is our ultimate goal. But it is a balance with federal guidelines and making sure we’re adhering to billing and coding regulatory guidelines.”

Brown also encouraged patients to inquire about billing if they have concerns.

“The challenge is providers are best at making diagnoses and teaching patients about their treatments,” Brown said. “Their skill set isn’t really in discussing insurance coverage, so it’s an uncomfortable topic. Because it’s so confusing, providers don’t always want to jump into that conversation. We do our best to educate and communicate that way, to have one-on-one communications with patients at the point of care, and then also to work with our payors to try to advocate and simplify exactly how we bill.”

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