it’s a fine line b/t preventative and what is diagnostic. Most PCPs don’t know it. And mine is a dean @ Mayo! So it is a black box. or a crazy list like this one
I guess you could just tell them that you’re not bringing up any new issues and only want to do the stuff that is covered. Then, in fact, don’t bring up any new issues.
It’s been sort of hit or miss with mine. I have brought up new issues and it ended up being coded as a free visit. Sometimes all the labs are covered at 100% sometimes there’s one or two that aren’t. It’s always stuff that is deemed medically necessary so I get the benefit of the negotiated rate and it’s rarely been more than 20 bucks.
I do also have a very generous $700 ACA deductible, thanks Obama!, so it’s not the sort of thing that I sweat. I see her 2-3x annually anyway.
PS – there is one thing you have to be very sure of, and my doctor knew this one. They only cover this stuff once a year, and the year is a strict 365 days and not just your idea of “I saw her last year.” So look at the calendar and make sure you’re not violating the timeframe for either the visit or the labs.
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It’s really shady with colonoscopies. To get one as a screening test with no history of colon disease, it’s covered at 100%. If you had polyps last time or they suspect something is wrong, then it’s diagnostic and not free.
The original sin here is high deductible plans. If everyone has a reasonably low deductible with 100% coverage afterwards, there would be no need for all these special 100% coverage carveouts.
And this is also why a conforming vs. non-conforming plan with similar stats don’t cost the same.
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Or there is no need for special carveouts because you accepted paying 100% for such routine things when you chose a high deductable plan in the first place.
When something is routine and is paid in full for everyone, it isnt insurance. It’s just a mandatory medical cost baked into everyone’s individual insurance premium so it can appear to be “free”.
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How strict is this really? I’ve heard it before, it just doesn’t make sense, because it’s impossible to get an appointment exactly 365 days later every year. This could cause you to miss a full calendar year if you had an appointment on December 27, but next year the doc went on vacation early and isn’t back til January.
Everything related to benefits (rates, limits, deductibles, OOP maximums, FSA, HSA, etc) goes by calendar year. It would only make sense that my use of the benefits is also based on a calendar year.
That’s one way to see it but then again what is essentially already paid for by your premiums should be clearly defined and you should expect only what’s been paid for to happen during your physical visit. Anything not already paid for should be authorized specifically by the patient.
If you call a contractor to fix something in your house and they also find another issue, they will check with you that you also authorize them to fix the other issue, essentially approving a change to the contract with you.
The main issue with medical billing is that additional non-covered procedures are performed without explicit consent nor any quote of costs.
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I don’t know if it’s the visit or the labs, or both. My PCP definitely wanted to schedule the labs so that they were at least 365 days apart. Maybe this is something you would win on appeal?. Most people wouldn’t bother.
This was Blue Cross. Maybe yours is different?
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One little ray of light last time is that when I went to quest to get the blood drawn, they had some advance statement of what was going to be covered. Then I either pay on the spot or refuse the test.
This really should be the standard anywhere (routine) care is delivered.
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Yep.
https://kffhealthnews.org/news/tag/bill-of-the-month/
https://www.washingtonpost.com/wellness/2024/12/20/colonoscopy-polyp-bill-northwestern-chicago/?
I think his ignoring collections would work, since they can’t report to credit agencies for med debt? Can’t go back to the hospital/provider though…
It’s a valid civil debt they could sue him over, although I don’t know if the hospital system wants the adverse publicity after it got in the Post.
Yes! You can’t get a “free” colonoscopy IIRC more than once every 10 years. If you’re poiypy or IBSy, then then it’s not really screening, unless you want to wait 10 years. Then you’ll be covered.
My experience with BCBS of IL, NC, and SC is that they are very strict. My GP schedules my next physical when I complete my current one. They will not schedule it for less than 365 days unless I sign a waiver. The waiver “roughly” says that I am aware of my insurance requirements for “annual wellness visits” and am willing to schedule a visit within 365 days of my most recent “annual wellness visit”. I decided to accept their suggestion of a wellness visit at 366 days of my most recent one.
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I agree. I suspect his is why there are so many specific/particular rules for “annual wellness” visits. If EVERYONe had to pay for their visits, even if it’s a miniscule co-pay, I suspect the annual physical cost might be closer to $150 (including labs), and routine (screening) colonoscopies/mammographies would be significantly less than current rates.
I googled it. Seems like the meaning of “annual” depends on your insurance. For some it’s “365 days,” for others it’s “calendar year.”
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That’s why I said my GP. 
Every health insurance provider/manager that I’ve had since Obamacare was invented, it is 365 days. Our vision insurance is calendar year … as in I can get my eyes checked in December, and again in January and they’re both covered. That seems a little idiotic, but dem’s de rules.
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Here’s a guy who interviewed the CEO killer months before hand, so a pretty good perspective on what he believed, his mental state, etc.
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Agreed. Something like that should be part of the mandates as well.
Allegedly? The last thing you linked was a fake! 
Oh another shitty thing I just remembered in the healthcare space. Almost no doctors practice independently anymore. They’re all part of large hospital groups, and you go into a building and into an office that looks like a normal doctor’s office, but guess what, it’s not. You get billed for a separate facility fee for using it, lol.
It’s usually covered in-network and insurance doesn’t allow much for it, but woe be upon you if somehow it’s not covered (deemed not medically necessary or whatever) and you have to pay list price for it.
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The “not medically necessary” trap is like when you come in to get some ancillary form filled out and aren’t sick, then the office codes the visit accordingly.
We could fix all these edge cases by (Congress) saying “anyone paying cash gets the benefit of whatever usual and customary would have been” or peg it to something like X percent above the Medicare rate.
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