I Was Billed $450 for a Wellness Exam—How Can I Fight This Charge?

In 2010, Barack Obama signed the Affordable Care Act into law. It was an initiative intended to address rising healthcare costs. The ACA, also known as “Obamacare”, essentially mandated that American citizens had to buy medical insurance. While the inevitable result of fewer uninsured people was lauded, Obamacare also increased the cost of healthcare and insurance. A Heritage Foundation study found that Obamacare actually doubled the average cost of individual health insurance in the US. As such, the healthcare industry has become much more fee preoccupied, often at the expense of patients.

Predatory Medical Billing

The labyrinthine world of insurance procedure billing codes holds tremendous power over medical patients who are responsible for copays. Once codes are submitted to an insurer, the fee amounts are practically set in stone, and disputes are often futile, regardless of whether or not they are in error. Medical offices and institutions are aware of this, and the chronic delays with insurance coverage payouts have accelerated the trend towards predatory medical billing. The add-on fees can be triggered by as little as an unintentional comment about an allergy or a headache. Those fees, however, can run hundreds of extra dollars per visit, per patient.  

A 26-year old man who recently moved to a new city had booked an appointment to meet with a doctor who accepted his insurance for the first time. What he had presumed would be a standard wellness exam and introductory meeting with a new physician to evaluate whether he wanted to become a regular patient turned into a $450 medical bill copay nightmare. He took to Reddit to garner opinions on what recourse options he might have. His details were as follows:

• The poster’s appointment was predicated as a routine new patient’s first visit. 
• It was scheduled as a wellness exam and a first meeting for the poster to determine interest in becoming a repeat patient.
• During the exam, the doctor casually asked the poster if he had ever had his allergies diagnosed. 
• The poster replied that he didn’t want to undergo the expense and was not overly concerned about allergies.
• When the poster saw the bill from his insurer, it covered $150 for the wellness exam but billed him $450 in copays for blood work and allergy consultation.
• The poster called the doctor’s office and was informed that because they discussed a topic outside of preventive care, the switching of the billing code was justified.
• Insurers are very unlikely to reverse their payout claims unless resubmitted by the physician’s office.

Predatory Billing as Standard Operation Procedure

The respondents on Reddit included both sympathetic patients sharing their own horror stories, as well as people in the insurance billing sector who soberly explained the current billing experienced by the poster has now become par for the course.

• One insurance billing industry respondent said that the poster would have an uphill battle ahead of him. In their experience, the doctor’s office would be reluctant to alter CPT codes or, if anything, might double or triple bill by adding on extra services, regardless of whether or not they were ever performed!
• Another experienced billing respondent felt that the fees were on the high side but probably would be defensible since a “wellness exam” presumes one is currently under the physician’s care, so any new records or info introduced at the appointment could justify a full consultation fee.
• One patient had mentioned having past migraines, and their billing code switched to a “diagnostic” visit, even though no action was taken by the doctor to address migraines.
• One experienced billing victim stated that in today’s healthcare environment, one should never ask questions or ask for referrals unless one confirms in advance if doing so would still be categorized as preventive. Any response other than “yes” should be a sign to decline asking the question or for the referral.
• One physician’s office has a sign on the waiting room wall that lists what is considered “preventive”, and explicitly notes that talking about existing conditions is NOT considered “preventive”, and may require a separate appointment in order to qualify. 

Sadly, this is the current state of healthcare insurance and billing in today’s America. Hopefully, HHS Secretary Robert F. Kennedy’s initiatives to reform healthcare, nutrition, and the pharmaceutical industry will improve the overall health of US citizens and make medical appointments less necessary in the future. 

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