What if I talk to my provider about a problem I am having?
An annual exam or preventive care exam is a comprehensive exam with your primary provider for the sole purpose of preventive care. An annual exam does not include the discussion of new problems or detailed review of chronic conditions.
What is the difference between a preventive or wellness exam and a problem visit?
Preventive/wellness exams can help you stay healthy and catch problems early. Diagnostic visits and tests are used to diagnose and recommend treatment, if any, for current health problems or changes in chronic conditions which have already been diagnosed. Diagnostic tests are ordered by your provider when you have symptoms
Can I have a preventive/wellness exam and a problem visit at the same time?
That depends. If you are scheduled for a preventive exam and have a sudden onset of an illness that needs to be addressed, more than likely, your provider will use the time to address the currrent problem and have you come back at another time for your preventive exam. Remember, preventive/wellness exams are done in the absence of any problems. If the presenting problem is minor AND your provider has time to address the issue, she or he may agree to do both.
I want my provider to address both my routine care and the problem I am experiencing today. Will my insurance pay?
If your provider agrees, she/he will bill your insurance for the preventive exam which should be covered as long as you have wellness benefits. Your provider will also bill for a problem focused exam which will not be processed by your insurance the same way as your preventive visit. Problem-focused visits will be processed according to the "rules" determined by your insurance company. They may allow payment for both codes but typically, the code we use to bill for the problem(s) addressed will require a copay or co-insurance. if you have a deductible to meet you may be responsible for the full allowed amount (the difference between the providers full billed charge and the contracted rate your provider has agreed to accept as payment in full).
My insurance denied the charge for the problem focused exam but said if you had coded it differently it would have been paid. Can you change the code?
That is considered fraud. All providers have the same set of standards they must adhere to for billing their services. The documentation in the medical record must support the code(s) the provider submits to your insurance company.
