A few weeks ago, I saw my primary care provider for a scheduled physical exam or what the health insurance industry now likes to call a “wellness checkup”. If you recall, a major selling point of the Affordable Care Act (Obamacare) is that we are moving from a fee-for-service world to a place where value takes precedence over volume. Physicians will be rewarded for keeping people well. That is why most heath insurance plans, even those with high deductibles, now cover scheduled, annual wellness exams at 100 percent.
So imagine my shock and surprise when I received the explanation of benefits (EOB) summary from my insurance company for my wellness checkup. The first shock was seeing the total amount that had been billed to my insurance plan–more than $880. The second surprise came when I saw what my physician, or more likely his coders, had charged for my visit.
Actually, I had been charged for two visits on the same day. There was one charge for $300. That was for my wellness checkup. There was a second charge of $225 for an office visit. The remainder of the total charges were a vaccine administration fee of $36, and a charge of more than $300 for the shingles vaccine. The good news was that my insurance company would pay for all but $126 of the total charges. None-the-less, I decided to investigate a little to find out why my “wellness checkup” was costing both my insurance plan and me a whole lot more than I would have anticipated.
After a call to the billing department at my physician’s office and another call to my insurance plan, here is what I learned. First, how was it that I was being charged for two, separate office visits on the same day? Well, it turns out that I was billed $300 for the wellness checkup, and an additional $225 for an issue that was discussed during my checkup. Now, the issue that was discussed is nothing new. I travel the world on business and I occasionally suffer from insomnia. During my physical exam, I mentioned to my doctor that I was still having problems with sleep. I told my physician that I didn’t like to use the sleeping pills he had prescribed previously because they made me feel groggy in the morning. I asked if he had any other ideas. He mentioned another drug that he often prescribes to help people like me, and I agreed to give it a try. Well, it turns out that that five minute discussion during my wellness checkup about my ongoing problem with insomnia was the reason for the extra $225 charge.
Now, let’s examine this issue. Isn’t the whole purpose of a wellness exam to survey the patient’s current health status, do a physical exam, review any medications the patient is taking, make any needed adjustments to those medications or recommend new treatment options? Well, that’s what I thought but apparently I was mistaken. The billing office told me that the discussion about my sleep problem was apparently outside the limits of my wellness checkup and hence the extra charge. Please! My insurance plan told me pretty much the same thing. I asked if this was a common practice, and here’s what they told me. The Affordable Care Act mandates that insurance companies cover wellness checkups in full. It is also expected that physicians will accept the discounts that insurance companies pay for these services. That being the case, it is now becoming a common practice for physician billing offices to code things in such a way that physicians can charge extra during wellness exams.
And what about that charge of more than $300 for a shingles vaccination? I mentioned to my insurance company that I was a bit on the fence when my doctor asked me if I wanted the vaccine. We discussed the pros and cons and I decided to do it, but we never discussed the cost. I told my insurance plan representative that perhaps my doctor should have mentioned the cost while discussing this optional vaccine with me, especially since it was priced at more than $300. To that she said, “Actually, I doubt that most providers have any idea how much the vaccine costs”. “Well, maybe they should”, I said.
Even though, I too am a physician, I am perplexed by these fees. I do understand that my doctor won’t get anywhere near the full $880 for my “wellness checkup”. It will be discounted by my insurance plan. But I wanted to vent just a little over what continues to be a significant source of consumer dissatisfaction with our healthcare system—the complete lack of price transparency. Surely we can do better than this. What do you think?
Bill Crounse, MD Senior Director, Worldwide Health Microsoft