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Annual physical and a high deductible plan
Old 03-04-2015, 08:53 AM   #1
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Annual physical and a high deductible plan

I signed up for a $5k deductible ACA plan with Kaiser for 2015. Prior to that I had been covered by Federal BCBS.

I went in for an annual physical a couple of weeks ago. I thought I was due for a pap and pelvic but I was told it isn't due for 2 more years. So I chatted with my doctor (she had been my doctor for 10 years before she changed jobs and went to Kaiser). I basically gave her a status on my health. I mentioned that I still had insomnia and she offered to write a prescription. I told her I was going to try using pot and see if that helped (it's legal in Washington and Oregon for recreational use) so she said she'd put a note in my file and if I changed my mind I could email her and she'd write a prescription for me.

I got a bill in the mail for over $300 That charge has to be coming from the note she added to my file because other than listening to my lungs and heart and taking my pulse and BP nothing was done.

I called Kaiser and requested a review of the charge. The woman I spoke with told me there is a list of what is covered under preventative care and if I stray outside of it I will be charged. The problem I have with this is the lack of transparency. The doctor was going to order a blood test and I asked her if it was covered under the annual physical. She didn't know. I asked her if she knew what the cost would be if I paid out of pocket and she didn't know that either. I told her I'd like to skip the blood test due to the $5k deducible and I would price shop to have it tested elsewhere.

Here is a .pdf of what Kaiser covers for the cost of the monthly premiums:

https://healthy.kaiserpermanente.org...lth_reform.pdf

I think I made the right call on telling her not to order a blood test. I don't know if I would qualify as "being at higher risk for cardiovascular disease." Plus, I don't know if she would have ordered a CBC or just a cholesterol/glucose test.

I can get a cholesterol/blood sugar test, have my BP and pulse taken, have my fat measured and be weighed at a local hospital for a $35 screening fee. Plus I can discuss my diet, exercise and sleep habits with them and not have to fear an additional charge.

I can afford the $5k out of pocket every year if needed; it's the lack of transparency I am having a problem with. There is no other part of my life where I would order a service without knowing the cost up front.
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Old 03-04-2015, 08:58 AM   #2
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Helen, this is typical. For the annual physical, they will typically pay for a basic blood test though.

However, if you discuss anything about it with your doctor, then you'll get a charge from them for the additional dx code.

This steamed me quite a bit when I went high deductible years ago. Since then, my Dr. has a big sign up front explaining that this can happen.

So now, when I go in for my physical, I just shut up. The key is the blood results. And of course, also get some other basic tests. But I don't talk to him except to answer the questions without elaboration, and in a positive way.

It is a terrible game.
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Old 03-04-2015, 09:15 AM   #3
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Wow. Are you at the point in your life when you actually need an annual physical?
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Old 03-04-2015, 10:07 AM   #4
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I think that the coding that goes on and the reimbursements are pretty bad.. call you doc and request that they go back and change the coding to what it should be...

As an example... I had a colonoscopy and they were telling me that if the doc found anything then I would be responsible for the cost.... I told them upfront that I would not pay for the whole procedure even if he found something.... that the procedure was covered and finding something did not change that fact... I found it interesting that they did find 'a small polyp', but the coded it correctly and I did not pay anything except for the analysis of the polyp...
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Old 03-04-2015, 10:28 AM   #5
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Originally Posted by Texas Proud View Post
I think that the coding that goes on and the reimbursements are pretty bad.. call you doc and request that they go back and change the coding to what it should be...

As an example... I had a colonoscopy and they were telling me that if the doc found anything then I would be responsible for the cost.... I told them upfront that I would not pay for the whole procedure even if he found something.... that the procedure was covered and finding something did not change that fact... I found it interesting that they did find 'a small polyp', but the coded it correctly and I did not pay anything except for the analysis of the polyp...
I had a problem with a colonoscopy where the doctor was going to code it as a follow up instead of a preventive. A preventive would be 100% covered but the follow up was not. Their reason was that 4 years ago a couple of small polyps were found and removed. None were cancerous. After arguing a little bit, I just went to a doctor that would code the procedure correctly (IMHO). If I had a colonoscopy and the found a situation that needed me to have a second colonoscopy soon after the first one, I agree it would be follow up. The only reason I was having a second colonoscopy is that it was recommended by my original doctor to check again in 3 years to see if any additional polyps had developed.
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Old 03-04-2015, 10:36 AM   #6
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This is an interesting article on colonoscopies under the ACA. The issues of polyp removal and follow up colonoscopies are discussed.

ACA: When Is a Screening Not a Screening? | Medpage Today
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Old 03-04-2015, 02:25 PM   #7
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I got a bill in the mail for over $300 That charge has to be coming from the note she added to my file because other than listening to my lungs and heart and taking my pulse and BP nothing was done.
Is $300 the amount your doctored billed the insurance company? Even if you have to pay you should only have to pay the negotiated rate your insurance company has with the doctor which should be a lot less than that. I've gone to specialist under my HDHP for exams and the negotiated rate that I had to pay was always under $100. For my annual physical my doctor bills about $150 but only gets about $50 from the insurance company.

Your insurance company should list what is included under preventive care, typically standard blood test and vaccinations are included.
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Old 03-04-2015, 02:58 PM   #8
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I had a physical, but I also discussed some ongoing issues with things we are treating, so the physical part was covered, but I did have to pay a follow-up visit fee, which is $67 as negotiated by my insurance company. I pretty much expected that.
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Old 03-04-2015, 03:05 PM   #9
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Originally Posted by 6miths View Post
Wow. Are you at the point in your life when you actually need an annual physical?
My high deductible plan requires an annual physical, other wise I have higher out of pocket max and higher co-pays.
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Old 03-04-2015, 03:10 PM   #10
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Helen..You have just described my fear for when I have to go to the doctor under my new ACA compliant bronze plan. Nothing is paid for and I have to pay for everything that is not preventive until I hit the $6K deductible. My problem is I have no idea what those cost might be. If this plan doesn't work well for me this year I can always change it next year..but it will be a couple or three hundred higher premium each month.
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Old 03-04-2015, 03:14 PM   #11
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Wow. Are you at the point in your life when you actually need an annual physical?
I'm curious what frequency you'd recommend, just asking (really)? Annually doesn't seem out of line to me, in my case it's the only time I've seen my GP in years.

In fact, he was going to drop me if I didn't come in for an annual physical, it surprised me at the time, but not entirely unreasonable IMO.
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Old 03-04-2015, 05:41 PM   #12
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Originally Posted by zinger1457 View Post
Is $300 the amount your doctored billed the insurance company? Even if you have to pay you should only have to pay the negotiated rate your insurance company has with the doctor which should be a lot less than that. I've gone to specialist under my HDHP for exams and the negotiated rate that I had to pay was always under $100. For my annual physical my doctor bills about $150 but only gets about $50 from the insurance company.

Your insurance company should list what is included under preventive care, typically standard blood test and vaccinations are included.
The total is $376 unfortunately, $313 is my share. The bill doesn't give me enough detail to ascertain exactly what the charge is for. I am glad I asked them to review the charge, for all I know it was coded wrong. This lack of transparency is really wrong.
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Old 03-19-2015, 06:32 PM   #13
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After having high-deductible insurance for many years, I just moved to a zero deductible plan because of these sorts of issues.

I tell everyone I speak with at my annual physical that everything needs to be coded preventive, and if it's not then don't do it. In spite of that I've had situations where things were miscoded and the insurers and doctors point fingers at each other.

I find that although these issues mostly get resolved in the end, they make me afraid of getting care I need. I'll probably alternate years in high and no deductible plans going forward, trying to bunch up my care in the no deductible years.
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Old 03-19-2015, 07:15 PM   #14
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This happened to me this year and has happened in the past. Went in for a physical and the doc ordered some routine bloodwork. Some was covered, but $7 worth wasn't covered. Must be something he orders for the over 40 crowd and since I'm 34 it wasn't covered for me though maybe a good idea.

It's $7 and wasn't worth inquiring why I have to pay for something that's preventative in nature (the excuse probably being it's "diagnostic for some condition, therefore not preventative"). I would spend some serious time fighting $300 charges though!
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Old 03-19-2015, 07:36 PM   #15
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This happened to me this year and has happened in the past. Went in for a physical and the doc ordered some routine bloodwork. Some was covered, but $7 worth wasn't covered. Must be something he orders for the over 40 crowd and since I'm 34 it wasn't covered for me though maybe a good idea.

It's $7 and wasn't worth inquiring why I have to pay for something that's preventative in nature (the excuse probably being it's "diagnostic for some condition, therefore not preventative"). I would spend some serious time fighting $300 charges though!
This happens to me every year. I get my mandatory physical, I get billed for tests. Sometimes the doc coded it wrong, sometimes the insurance company screwed up. Today I was on the phone to get the charges dropped, but got stuck for a $20 hepatitis C test that doc though everyone my age should have - insurance company wouldn't budge on that.
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Old 03-19-2015, 10:15 PM   #16
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Originally Posted by 6miths

Wow. Are you at the point in your life when you actually need an annual physical?

Quote:
Originally Posted by Midpack View Post
I'm curious what frequency you'd recommend, just asking (really)? Annually doesn't seem out of line to me, in my case it's the only time I've seen my GP in years.

In fact, he was going to drop me if I didn't come in for an annual physical, it surprised me at the time, but not entirely unreasonable IMO.
Sorry I haven't been on for awhile. I wouldn't really recommend anything and would have to go off and check what the experts say but my understanding is that the annual physical is not very valuable as far as changing outcomes go and if it is going to cost significant dollars and aggravation then even less reason to get it. There are certainly many age specific things that have been shown to be beneficial but an annual physical is not one of them as far as I know.

http://www.nytimes.com/2015/01/09/op...ical.html?_r=0
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Old 03-19-2015, 10:43 PM   #17
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Annual physical exams may not be necessary after all | Lifestyle from CTV News
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Old 03-19-2015, 10:55 PM   #18
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Last month I decided to for a physical. It had been 2 years since my last one, and I had just turned 60 so I get a shingles shot for free. The physical is free as well, even though they determined it had been over 10 years since my last tetanus shot and I got a DPT shot as well, which should also have been free.

The doctor visit cost me $3 and the lab work $27. I had just finished a year of appeals and getting a $1,500 charge down to $60 so I didn't even consider arguing or calling over $30 to see what was done that wasn't covered.

As to the value of the physical I can't really say but I do like to see all the numbers from the blood work in the normal range. I got a clean bill of health but was in the ER 6 weeks later with atrial fibrillation. (first ever heart issue)

At the ER they also did a full blood test and everything was still in range. A few hours later at the docs the EKG was perfectly normal, my heart had reset itself.

I should probably look to see what to expect to pay for the cardio doc next week, but it is what it is. I have made sure he and the facility he works in are in network, but that's about it.
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Old 03-19-2015, 11:19 PM   #19
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Oh Gawd.

I just had an annual, and I motor mouthed like a little whiney kid.
Now maybe I'll get a charge for chatting

A few years ago, due to some miscoding, I had the pleasure of fighting with the insurance company over a $1,000 charge. Sure I won in the end, but it does make one shy about treatment/tests even when the doc orders it.
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Old 03-20-2015, 09:11 AM   #20
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Just had my "annual routine physical" this past January. Talked a lot about different stuff. My health insurance website has no record of any claim being made though. Nothing in mail to me either. Interesting. Maybe the doctor learned his lesson from me a few years ago when I refused to answer any questions he had for me, and stated that I was not answering or asking any questions since I did not want to be charged more. I also stated that I thought it was sleazy to charge more money for actually trying to talk about one's health at a visit one was already paying for.
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