Not What it Seems

Bob posted about a woman who was charged for “asking too many questions.”  The article in question is about a woman, Susan Krantz, a registered nurse who was confused by her bill. The article's title - "Questions can trigger split charge" - is misleading, as no one is charged for asking too many questions.  What happened in her case is that she went in for a wellness visit and then asked the doctor about a problem, a sore hip.  At that point the visit went from a regular wellness visit to a sick visit or as the article points out, “an “acute care” matter.”

By current policy, there is no charge, referred to as co-pay or out of pocket expense, on an annual wellness visit.  What is misunderstood is that once a person brings up an acute care issue, such as an injury or illness, or if in the course of the exam the physician discovers an acute care issue, such as a lump or other malady, and then the appointment becomes a sick visit and is billed accordingly.  This billing is subjected to a deductible and co pay, which is the patient’s responsibility.  CMS defines a wellness visit as:

As of 2012, the annual wellness visit benefit includes the following services:

■ Routine measurements, such as your height, weight, blood pressure, and body mass index (BMI);
■ Review of your individual medical and family history;
■ Review of the medications, supplements, and vitamins that you are currently taking;
■ Discussion of the care you are currently receiving from other health care providers;
■ Review of your functional ability and level of safety (for example, your risk of falling at home), including any cognitive impairment, as well as a screening for depression;
■ Discussion of personalized health advice that takes into account your risk factors and specific health conditions or needs, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition;
■ Discussion of referrals to other appropriate health education or preventive counseling services that may help you minimize or treat potential health risks;

This list does not include care for acute problems, such as the sore hip brought up by Ms. Krantz.

The article states, “In a written statement, the medical provider said that “the insurance company may require that patients pay or make a co-pay for services beyond the ‘preventive’ part of the appointment.”  The moral of this story is that in the end the patient is responsible for the consequences of any medical appointment with a medical provider, so be prepared.