That is a great question that comes up in our clinic almost daily. The simple answer is “insurance”. They have specific rules that we as providers and you as a patient must follow as part of our agreement as in-network providers and yours as the insured patient.
As providers, we are required to submit bills to the insurance company with very specific codes to tell the insurer why you were seen. There are wellness or maintenance codes and there are “problem” codes which can be acute issues or chronic diseases, and we must honestly code why a patient was seen.
Wellness or health care maintenance visits are for yearly exams (yearly physical) designed to provide routine health screening, labs, vaccines, wellness coaching, and setting you up for recommended procedures like colonoscopies, mammograms, etc. They can also include a brief review of long-term stable medical conditions, like refilling blood pressure or cholesterol medications that a patient has been on long term and the condition is stable. Most insurance companies give you one visit for this screening and maintenance of chronic conditions free of charge and co-pay.
Acute illness issues like strep throat or a rash, and new onset of issues that may be temporary or become long-term chronic problems like migraines, diabetes, or arthritis must not be coded as wellness exams. Your insurance company mandates these to be coded as problem-focused visits and we are required to collect a co-pay and you will need to pay the cost up to your deductible.
We know it is frustrating for you as patients and it is for us as providers as well, but we must follow the rules. Almost daily we see people who have saved a long list of “problems” to bring up at their physical. Many times they even say “I want to get as much done today because I get one free visit a year, so I made a list of ……..”. Unfortunately, that is not appropriate and we must schedule another appointment to work through their list of issues. If we, as providers, evaluate/workup/diagnose/treat new problems at a wellness visit and still code it as a wellness exam we are committing insurance fraud and can be heavily fined and removed from that insurance as a provider. As a patient, you can be kicked off that insurance, and all charges denied.
There is a second issue, and it is of at least as much importance to us. Of course, we don’t want to get fined and kicked off of an insurance panel, and our number one priority is your health and wellness. We strive to provide you with holistic, compassionate, expert, and complete medical care. It is impossible for us to thoroughly understand, accurately diagnose, and adequately discuss treatment options both natural and medicinal for a litany of problems in the few minutes left at the end of a 30-minute appointment.
Please help us to provide you with the best service and healthcare that we can and make separate appointments for your routine wellness exams and new or changing medical issues. Understand as well, if we made the rules they would be different, and unfortunately we do not and we are obligated to follow the ones they make for us.
~Dr. Lawrence Hutchison, MD
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