I Went in for a Physical Exam, Why Was I Charged a Co-pay?!

One of the BIGGEST complaints we would get from patients calling in about their bills was that the patient was scheduled and went in for a preventive/physical/well-care exam and then, suddenly, they were charged an office visit as well. That office visit triggered a copay to be charged to the patient, and unfortunately, both you and most providers have no idea what is truly inclusive in that yearly physical to document and code appropriately. What’s even more ironic is that different insurance companies (and even different policies from the same company) differ in what’s inclusive. Let’s explore what makes each different and what you can do to empower yourself.

Preventive/Physical/Well-Care Exam:

  1. Only allowed every 366 days (one year and one day)—make sure to ask, when scheduling, when your last one was. They will send you the bill if you schedule too soon!
  2. Most insurance policies don’t charge a copay for these, but some do, so ask.
  3. Medicare doesn’t allow for physical exams. You get one “Welcome to Medicare” exam, and they have well-care exams, which are not face-to-face with medical providers. I’ve linked the guidelines here https://www.medicare.gov/information-for-my-situation/your-welcome-to-medicare-preventive-visit.
  4. Each insurance company and policy varies, so know what labs and testing can be done or not with a yearly exam. What often happens is your provider will mark many things to “check” out, but they may not all be included in your policy, and you will get a bill.
  5. Follow this link written by a medical provider to help with some ideas around what is normally done during a physical: https://www.healthline.com/health/getting-physical-examination.
  6. Diagnosis code commonly used for adults: Z00.00.
  7. New Patient Physical Exam CPT code is 99381-99387 or Established Patient Physical Exam 99391-99397. The reason there is a range is because the age of the patient is tied to each of the variations.

Problem (Established Patient or New Patient) Visit:

  1. Used for any other type of visit in a medical provider’s office with face-to-face time, other than a physical.
  2. Usually has a copay or coinsurance.

With the high-level guideline attached, you can clearly see that if, during your visit, you step outside of that box, your provider can and will charge you for the additional service.  Physical exams don’t cover much other than a basic checking, and if you bring up ANY other issue—like, my stomach hurts, my knee is having pain—well, you have now entered a problem-focused visit.  That means you are going to be asked for a copay or charged one later. Some insurance companies don’t allow for these two types of visits to be done at the same time, so watch your EOB (explanation of benefits) in case they try to charge you in full for it.

For a provider to charge an office visit, they must do a full workup (HPI – history of present illness, PE – physical exam , etc.) and document it in your health record. If they don’t, they can’t charge you for it. If their billing staff sees the extra diagnosis codes but doesn’t review the record, they will automatically add the office visit on if the provider forgot, which they shouldn’t do, but they do anyway. Always ask for a copy of your records for the visit; that way, you can compare what they documented versus what they billed your insurance.

As you can see, there are many guidelines in the medical field that your provider must follow, and they can vary by insurance carrier and individual policies. It’s a confusing process all around, but you can advocate for yourself by knowing what your policy covers in your yearly physical exam and bringing it to your visit so that your provider knows their limitations.

Tips:

  1. Confirm that your physical is 366 days (one year and one day) from the last one.
  2. Contact your insurance company and confirm what is covered under your policy for physical exams. Write it down and bring it with you to your visit, so that your provider knows.
    1. Labs
    2. Tests
  3. If you are a Medicare patient, not Medicare Advantage, understand clearly what services you are entitled to receive, as they are different.
  4. During your visit or prior to your visit, clearly define with your provider of service what they include in their physical exam.

Definitions:

Physical Exam: Routine physical examination ensuring that you stay in good health. A physical can also be a preventive step. It allows you to catch up on vaccinations or detect a serious condition, like cancer or diabetes, before it causes problems. During a routine physical, your doctor can also check vitals, including weight, heart rate, and blood pressure.

Problem-Focused Exam: Limited examination of the affected body area or organ system

Copay: Fixed amount paid for a service.

Co-Insurance: Shared cost for a service (i.e. 80/20 split, meaning you the patient will pay 20% of the allowed amount on a bill).

Diagnosis Code (DX): Designated code that explains what is wrong with the patient.

CPT (Current Procedural Terminology): Codes that the healthcare industry uses to define the service they provided to the patient.

Explanation of Benefits (EOB): Document patients and providers of medical services receive from insurance companies after a bill for services is submitted for reimbursement. It outlines who provided the service, who received the service, the date the service was rendered, what was done, how much the charge for the service was, how much the insurance company is allowing for the service, how much they will pay, and how much the patient will pay.

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