When does insurance cover an Annual Wellness Exam?
One of the great benefits to having insurance is that preventive care is covered once per plan year in full by your insurer. What practices and insurance companies haven’t done a good job of is explaining what an Annual Wellness Exam (AWE) actually is.
What’s preventive care?
Preventive care is all the measures related to disease prevention, as opposed to disease treatment. Data shows that preventive care reduces overall cost and improves outcomes, so the Affordable Care Act requires that insurers pay for preventive care at no extra cost to the patient.
By definition, an AWE is preventive in nature. This means that your appointment is not for addressing specific issues, but is geared towards your doctor checking up to make sure everything is ticking properly. Think of it like a pre-purchase inspection if you or someone you know has ever picked up a vintage or second hand car.
When you book an annual wellness exam, make sure it falls on a day that you’re feeling well. This will help your provider get a baseline “you.” Your provider will ask you about lifestyle habits like exercise, drinking, smoking, drug or medication use, and will also listen to your heart, lungs and gut to name a few things to make sure everything sounds in order.
Some patients may be uncomfortable answering personal questions about their lifestyle. It is important to know that your provider needs the most complete picture of your health to make sure they deliver the best care possible, so be honest with them, they’re here to help, not be judgemental.
Preventive care includes:
- Documenting family and social history
- Listening to your heart and lungs
- Discussing lifestyle and risk factors
- Recommended screening tests based on age, gender and risk factors
- Recommended vaccinations
If your primary reason for visiting is not preventive, or you have specific symptoms you are evaluating (such as headache, back pain, a rash, fever or pain) then that is not preventive care.
Your insurance gives you one preventive appointment per year, so make sure to get the most of it.
Wait, why was I charged for my AWE?
It’s important to remember that your insurance will assess a claim based on what happened during the encounter, not necessarily the type of appointment you selected when booking. Some patients have a misconception that they get one free appointment per year, but it’s only free if it is preventive in nature.
If, during your AWE, you discuss or uncover a symptom that requires evaluation or treatment, that part of your appointment is not preventive and will be billed as a standard office visit.
One way to maximize your benefits is to schedule a separate appointment on a different date to discuss any prescriptions or issues you would like to address. You’ll still pay your deductible or copay for this, but by doing so, will maximize the time spent with your doctor for preventive services.
On laboratory charges
Occasionally, insurance companies may view certain lab work as non-preventive. It is always a good idea to ask your insurer what labs they will cover for an AWE before scheduling, so you can discuss with your doctor if pricing for certain tests is a concern. Your provider wants to ensure your health, safety and wellbeing more than anything, but can help offer alternatives if cost might be a constraining factor.
If you think you’ve been charged in error, the best place to start is to call your insurance company and ask them why. If there is a coding issue, your physicians office can get that fixed up for you. If you’re not sure, give your provider a call. While providers are often not able to directly affect change on lab bills, due to the third party relationship, your doctors office can often help you figure out if anything can be fixed, and what. Sometimes this comes down to the lab not getting your insurance submitted, or your provider may have under-coded the medical necessity for covering the lab work.
You can book a San Francisco primary care appointment online at Circle Medical.
