Why you get 2 bills for 1 visit to the doctor

Patient alert: If you're going to your doctor for an annual preventive exam and expect it to be covered 100 percent by your insurance company, think again.

You could be charged for an extra "office visit" if you ask questions about existing medical problems, such as high blood pressure or cholesterol.

It happened to me in 2012 when I saw my family doctor for an every-other-year checkup. My insurance paid $256, the total for the preventive exam. But the "explanation of benefits" showed that I also owed $74.60, my share of the $113 bill for an "office visit" — on the same day, in the same time slot.

Puzzled, I called my doctor, Dael Waxman at Elizabeth Family Medicine in Charlotte, N.C. He explained the second charge resulted from our talk about my elevated cholesterol level, which had been diagnosed previously. Because he documented that discussion and marked the billing code for evaluation and management of a cholesterol diagnosis, I was billed for the second visit.

I objected, believing that I should have been able to talk about cholesterol at a preventive exam. Waxman pretty much agreed. And because I hadn't been made aware in advance of the second charge, he deleted it from my bill.

I have learned since that it's not unusual to get this extra charge with a preventive exam.

In the past year or so, primary care doctors say they have struggled over how to manage their time during preventive visits when patients bring up questions about chronic medical problems. If the discussion in a preventive exam turns to previously diagnosed conditions, the code for that signals the insurance company to pay for an "office visit," which usually means a co-payment from the patient.

"It's very confusing, even for the doctors," said Dr. Dino Kanelos of Carolina Family Healthcare in Ballantyne, N.C. "I just finished (a preventive exam) with a lady who had 15 medical problems she wanted to discuss."

There are multiple factors at work here. This practice of billing for an extra visit began before the Affordable Care Act's insurance mandate took effect Jan. 1. But some doctors and insurance companies may be using this opportunity to more strictly follow guidelines about what qualifies as a preventive service under the act, and must be covered 100 percent without patient cost-sharing.

In addition, doctors are under pressure to document everything appropriately in the electronic medical record or they could be subject to Medicare reimbursement cuts in the future. That takes more time, so they have less time to handle extra questions from patients. And with the growing prevalence of high-deductible insurance policies, patients may save their questions for the preventive exam, hoping they can avoid paying the full cost of a separate medical visit.

"It's a Catch-22," Kanelos said. "I want to be able to say, 'What's going on? Is there anything wrong with you?' … In the old days, that's the way I picked up a lot of problems. … Now, it is hard to figure out what to do."

Because this is confusing to patients — and has led to more than a few objections like mine — some doctors have begun sending notices in advance, letting patients know they could be charged extra if they bring up questions that aren't considered part of a preventive exam.

Every doctor I talked to stressed the value of preventive exams. But they all admitted the coding issue is "complicated." Some of them blamed insurance companies.

Colleen Dey, Kanelos' office administrator, said insurers seem to have strictly adopted the list of preventive services outlined in the Affordable Care Act.

"They seem to be saying, 'We're required by law to cover these tests, so that's all we're going to do,' " Dey said.

But insurers say it's up to physicians to decide which codes to apply for billing purposes.

"We don't tell a provider how to code," said Lew Borman, a spokesman for Blue Cross and Blue Shield of North Carolina. If a pre-existing problem is addressed, "then the additional charge for the exam can be reported," he said.

"By reporting this way, the provider is indicating that a significant, separately identifiable service was rendered," Borman said. "The medical records should document the additional work. If it is not documented, it should not be billed."

Screening for cholesterol is part of a preventive exam.

"But if you have a history of elevated cholesterol, all of a sudden that becomes a diagnosis," Waxman explained.

"For you, obviously, cholesterol is prevention, trying to prevent a heart attack," he said. "If I was the patient, I could easily see myself thinking that. But in the medical world, it's a diagnosis. … That's no longer a preventive screening issue."

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