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Consumer Confidential: Does ACA cover annual physical?

By David Lazarus Los Angeles Times

Jim Bailey and his wife went in recently for their annual physicals. They came away with hundreds of dollars in charges for copays and tests.

Bailey, a 78-year-old Southern Californian, told me that he feels duped.

“The Affordable Care Act dictates that all annual physicals be provided at no cost to the policyholders – no deductibles or copays,” he said. “But that wasn’t the case with us.”

Nor will it be the case with anyone else – even though many Americans believe otherwise.

“There’s nothing in the ACA that guarantees a free checkup,” said Bradley Herring, an associate professor of health policy and management at Johns Hopkins University. “It’s surprising how many people think it’s part of the law.”

For consumers, this is perhaps one of the more confusing aspects of Obamacare, which does indeed cover certain free preventive services and so-called wellness visits but stops short of free annual physicals.

Complicating things, patients might go in for free preventive care covered by the law, mention some unrelated ailment and find out later they were billed for a normal office visit.

“This illustrates the somewhat arbitrary division between preventive exams, which the ACA seeks to encourage, and diagnosis and treatment, which remains subject to normal payment rules,” said Wendy Mariner, a professor of health law at Boston University School of Public Health.

“A visit to get a diagnosis for pain is not classified as preventive,” she said.

In Bailey’s case, what he expected to be a free visit to his doctor ended up requiring a $15 copay after the doctor decided to run an electrocardiogram test on Bailey’s heart. EKG tests are not a covered preventive service under Obamacare.

The doctor referred Bailey to a heart specialist, who did more testing and, said Bailey, found nothing amiss. Nevertheless, this second opinion entailed a charge of about $300.

Bailey’s wife, Peggy, 75, was billed $200 by her doctor for a mammogram. But when she pointed out that mammograms are a covered preventive service, the charge was removed. Nevertheless, she too had to cough up a $15 copay because her doctor went beyond the parameters of a free wellness visit for seniors by renewing a prescription.

The couple are insured by the Federal Employee Health Benefits program because Bailey is a former government worker.

Eligible preventive screenings and wellness visits are 100 percent covered by insurers under Obamacare, with no cost to the patient. Reimbursement rates can be higher for more comprehensive office visits, not to mention the added revenue from patients being responsible for copays.

Tomas Philipson, a professor of public policy at the University of Chicago, said it’s no surprise that some doctors may order additional tests or bill for a full office visit when all they’ve done is sign their name to a prescription form.

“This is how they get reimbursed by insurers,” he said. “It’s the same reason a doctor makes you come back to the office in two weeks to get your test results rather than just letting you call. It’s all about the reimbursement.”

That’s not to say this is what happened with Bailey. It’s entirely possible that his doctor believed an EKG was warranted, as was a second opinion by a specialist. As Bailey put it, “Better safe than sorry.”

It’s also possible that a clerical error was to blame for Bailey’s wife being charged for what should have been a free test. A copay for a prescription renewal – well, that’s technically legit, although Philipson told me that not all doctors are so money-minded.

“It’s hard to see why you’d code that as an office visit,” he said.

Coding is how doctors and hospitals handle bills. Every interaction with the health care system has its own code. How a doctor records a patient visit will determine if it was entirely covered by the Affordable Care Act or if it qualified as billable treatment involving an insurance claim.

Dr. Tanya Spirtos, a physician in Redwood City, Calif. said that “there’s no cookbook” outlining steps for coding when patients raise issues beyond the scope of an Obamacare-covered visit. “It’s all on a case-by-case basis,” she said.

A spokesman for the American Medical Association said that if a doctor records additional treatment in a patient’s file, “the coding must reflect that.”

The health care experts I spoke with described this aspect of the Affordable Care Act as a buyer-beware kind of thing: Know your rights and know where the pitfalls may lurk.

The official Obamacare website,, says that “most health plans must cover a set of preventive services – like shots and screening tests – at no cost to you.”

For all adults, these include screening for high cholesterol, depression, Type 2 diabetes, hepatitis, HIV and lung cancer, plus counseling for obesity, sexually transmitted diseases and tobacco use. Additional screening is available to women for anemia, urinary tract infections and other conditions.

A wide range of free preventive screenings are available for kids, including for autism, behavioral and developmental issues, hearing and vision. Most common vaccines are covered.

Medicare beneficiaries are entitled to a free annual wellness visit that includes routine measurements such as height and weight, a review of current medications and a check for any cognitive impairment.

Be careful during both preventive screenings and wellness visits about stepping outside the box, as it were. Even though it would seem perfectly natural to bring up all medical concerns during a trip to the doctor’s office, it’s clear that some doctors will recode your visit for the most trivial of reasons.

My suggestion: Before raising an additional health care issue, ask your doctor if, hypothetically speaking, such a question would result in a copay or other charge.

That at least puts the doctor on notice that you’re wise to any billing shenanigans.

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