Health Care Law ‘Wellness’ visit might not be free

As a cost conscious health care consumer, some health care law caution is called for, on your part, where those seemingly “free” annual checkups or well-child visits are concerned.

A young mother recently learned this lesson the hard way and shared her story with us.

This mother took her 10-year-old twins to their pediatrician’s office in January for their annual wellness checkups. A few weeks later, when she returned to the office for another pediatric visit, a worker told her that she had an outstanding bill of about $27 for what she had thought had been a free visit.

She was billed because a nurse had asked about her son’s attention-deficit-disorder medication, which had first been prescribed in October and then checked during a follow-up visit in November. The January appointment was also coded, in part, as a “medication check.”

The Affordable Care Act now requires most health insurance plans to cover the entire cost of preventative office visits, so patients like these may, and frequently do, feel blindsided when they are billed by their doctor’s office after an annual checkup. The issue at hand may be the “oh, by the way” questions that patients pose about previously undisclosed health problems while seeing their doctors. However, the charges may stem from a health issue that a doctor discovers during these visits.

“Those problems are not part of a regular well visit,” said Dr. Sarah Sams, who teaches coding through OhioHealth’s Grant Family Medicine residency program in Columbus. “It takes time to do a thorough job with preventative care,” Sams said. Sams also states, “An illness that comes to a doctor’s attention during a wellness check sometimes must be addressed on the spot, but it can put doctors behind schedule. And if doctors don’t bill for all the services that they’re providing, they’re not going to stay in business. If anything, doctors and their offices probably underuse the billing code that triggers compensation for problems that the doctors end up evaluating or managing during a wellness visit.”

This all begs the question of “What exactly IS covered:

For Adults

  • Screening for abdominal aortic aneurysm, alcohol misuse, blood pressure, cholesterol, colorectal cancer, depression, Type 2 diabetes, HIV, obesity, sexually transmitted infection prevention, syphilis and tobacco use
  • Aspirin use
  • Diet counseling (for those at higher risk for chronic disease)
  • Immunization vaccines


For Women

  • Screening for anemia (in pregnant women), breast-cancer mammography, cervical cancer, chlamydia (in younger and high-risk women), gestational diabetes, gonorrhea, hepatitis B, osteoporosis, Rh incompatibility, urinary-tract infections
  • Breast-cancer genetic test counseling
  • Comprehensive support and counseling for breastfeeding
  • Contraception
  • Counseling for sexually transmitted diseases and domestic and  interpersonal violence
  • Folic-acid supplements
  • Human papilloma virus DNA test
  • Well-woman visits for those under age 65

For Children

  • Screening for autism, blood pressure, cervical dysplasia (in sexually active girls), depression (in adolescents), development, dyslipidemia (for children at higher risk of lipid disorders), hearing, hemoglobin, HIV, hypothyroidism, lead, obesity (as well as counseling), phenylketonuria (a genetic disorder in newborns), sexually transmitted infection prevention (as well as counseling), sickle cell, vision
  • Behavioral and oral health-risk assessments
  • Height, weight and body-mass-index measurements
  • Immunization vaccines
  • Iron supplements
  • Medical history
  • Tuberculin testing (for children at higher risk of tuberculosis)

As is evident to all of us who follow ACA on a daily basis, there are constant changes and ramifications of this law.  Please let the health care professionals at the Merriam Agency know how we may be of assistance guiding you through this process.

Shannon McMeel
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