Healthcare reform now requires health insurance to cover preventive screenings at no cost to the patient. (I am talking about under-65 health insurance, not Medicare.) That means an annual visit to a primary care physician, nurse practitioner, or a physician’s assistant.

Note: The new rules apply to new health insurance plans or insurance policies that began on or after September 23, 2010.

People are encouraged to get these screenings even if they have a high-deductible health insurance plan. But it turns out some people have been surprised to find their free visit to the doctor resulted in a substantial bill. The surprise bill is due to the doctor going beyond the annual consultation and providing additional services, such as discussing symptoms that would require a diagnosis of a problem.  Apparently this is beyond the scope of a consultation for a physical, and results in the doctor generating another bill – something the insurance company is not required to pay if the patient has a plan with a deductible that has not been met.

In Connecticut, two patients filed complaints with the state’s Attorney General when they got surprise bills from what they thought were annual physical consults with their primary care doctors. They assumed they would have no co-pay for the visit to the doctor.

According to an article in The Day newspaper in New London, Connecticut:

[Doctors] are able to tack on these extra fees because there are no set guidelines by the American Medical Association or any other medical body that specifies exactly what an annual physical should include. This permits doctors and medical practices to unilaterally decide what is included and what they can bill for extra.

“We discovered,” said Attorney General spokeswoman Susan Kinsman, “that the threshold determination of when significant additional services are rendered is made largely on a case-by-case basis and … appears to permit services that may seem minor to a layperson, to be considered significant to a physician or billing agent.”

The two patients in Connecticut who complained were put on a “do not serve” list by the Hartford Medical Group, which is one of the largest medical practices in the state of Connecticut. They got some vindication from an investigation by the state’s Attorney General. The Hartford Medical Group agreed their doctors should advise patients when an examination goes beyond the scope of a preventative wellness exam that would generate another bill.

Medicare now covers more preventive services.

Seniors are being encouraged to take advantage of these “free” Medicare benefits. But they might be surprised to find they actually need to pay something because of the scope of the appointment with their doctor.

A client of mine said she was surprised to get a bill for a $40 co-pay when she went for her annual exam with her gynecologist.  She is enrolled in a Medicare Advantage plan. As we talked about the bill, she told me she has a particular female condition  – and I surmised that the doctor was doing more than an annual exam, which resulted in the co-pay to see a specialist. My client was not upset with the co-pay, but she was happy to understand why she had to pay it.  Of course, this information probably should have come from the doctor rather than an insurance broker.

The list of preventive services covered by a person’s health insurance can be found at http://www.healthcare.gov/news/factsheets/2010/07/preventive-services-list.html  This is not the Medicare list.  This is for people under 65.

For a list of Medicare-covered preventive services look here: http://www.medicare.gov/navigation/manage-your-health/preventive-services/preventive-service-overview.aspx