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Jim & Alice

Did ACA change Annual Exam coverage?

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I am not seeking to re-argue the ACA Bill – but did it change what is included in Wellness Coverage? I just went through a process with United Health Care where they stated that coverages for annual exams were changed by the ACA. As a result, we had to pay for routine blood tests that we did not have to pay for before. Here's the story:

 

My wife and I left to go fulltime in January of 2013. We were in our early 60’s, good health. We contracted with Golden Rule Insurance (United Health Care) for a $10K High deductible Health policy, with HSA, that covered wellness care (annual checkups). Any other charges went to “deductible”. (ie, we pay)

 

Treatments:

  • January 2014 - We both had Annual Checkups. Wife had major Medical Procedure.
  • January 2015 - Wife had an annual checkup. I transitioned to Medicare.

Problem:

  • March 2014 - Received a bill to pay for my annual exam blood laboratory tests performed in previous January 2014. I formally appealed that, as it should be covered by annual exam coverage.
  • April 2015 - Appeal process concluded after 15 months, many, many, phone calls to providers, Golden Rule, and finally a formal letter of appeal backed by a Doctor Statement. Conclusion - we must still pay for two out of four ‘codes’ for blood tests. Reason – ACA changed what is covered in Annual Exam.

 

Additionally, as a side consequence of my appeal, United Health Care also determined that we were improperly charged for codes in 2014 for my wife's annual exam, and for her procedure. There will be a refund of some amount.

 

While I am glad to be getting money back, I still have concerns that an Annual Exam is no longer a ‘standard’ annual exam as we knew them. .. and we will have to pay. Anyone else encounter changes in their annual exam?

Thanks.

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Was your blood work done while you were covered under Medicare?? If so the issue may be how your Dr office coded for diagnostics. The diagnosis codes for say cholesterol screening must reflect a current medical condition that is related to cholesterol increase

Since Medicare is the primary it is then Medicare who decides if this is a covered procedure and your secondary follows suit

 

Example: Ron has very low cholesterol numbers. Evev though he has a heart problem its not affected by cholesterol. There for his labs for this screening are not covered by Medicare and so our secondary doesn't pay either.

 

In actuality this was how health insurance has always worked and not a result of new health care act.

 

I encountered this many times for years doing medical billing as a nurse for a family Dr.

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...I am not seeking to re-argue the ACA Bill – but did it change what is included in Wellness Coverage?...

My understanding of the ACA is that it requires all health insurance policies to include pretty specific items in the free Annual Wellnes Coverage. I doubt that at least the less costly plans include anything beyond what the law specifically requires. Prior to the ACA, I do not believe there was any standard requirement for annual wellness coverage and if offered in a policy, what was covered and what was not was up to the insurance company depending on the specific policy.

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We have Humana, and I recently discovered that our old plan was grandfathered under the ACA. Therefore it does not cover preventative care without a $30 copay. Might this be the case with your policy? Other than that, it is a pretty good plan, comparable to the ACA Gold Plans. However the annual deductible and the premiums keep going up every year. I certainly could not afford it if my employer didn't pay 75%. Still our annual premium is $4,524/yr. This means that the policy costs over $18k/yr! Because it has gone up so much my employer has to cut corners elsewhere. They used to buy us a life insurance policy equal to 3 times our annual salary. Now everyone only gets a small $10,000 burial policy, regardless how much they make. Bonuses and raises have also been greatly reduced too. All they are doing is shifting money from one pocket to another. There is not, nor can there be any net increase in total compensation through legislation - only through an increase in profits to fund it. All they are doing is dividing up the compensation fund a little differently, just like insurance benefits. The insurance companies actuaries know how much they can afford to pay for each procedure, so if they decide to give you more in one area, say in zero copay preventative care, then the copays for other things must go up, like drug or emergency room copays. There can be no net gain unless people suddenly get healthier and require less health care. This may happen slowly, through social change, (but now the Boomers, of which I am one, are the bubble passing down the hose of our nations health costs, so our health care costs will not be reduced until most of us have passed out of the hose - have died.) In the mean time there is nothing anyone can do, short of denying or limiting medical care, to reduce overall health care costs in a material way.

 

Chip

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Was your blood work done while you were covered under Medicare?? If so the issue may be how your Dr office coded for diagnostics. The diagnosis codes for say cholesterol screening must reflect a current medical condition that is related to cholesterol increase

Since Medicare is the primary it is then Medicare who decides if this is a covered procedure and your secondary follows suit

 

Example: Ron has very low cholesterol numbers. Evev though he has a heart problem its not affected by cholesterol. There for his labs for this screening are not covered by Medicare and so our secondary doesn't pay either.

 

In actuality this was how health insurance has always worked and not a result of new health care act.

 

I encountered this many times for years doing medical billing as a nurse for a family Dr.

 

I"m afraid you are correct. However, it is a contradiction. The entire purpose of preventive medicine is to discover a medical condition before it is advanced so that it can be treated. This is the principle of preventive medicine which proponents claim will ultimately reduce the overall cost of medical care. And, this was a major selling point of the ACA that even the lowest level policies would cover preventive medicine.

 

Following Medicare's logic on cholesterol screening, all blood testing could be disqualified from coverage because they didn't reveal a medical condition associated with that specific test. PSA testing disallowed since no prostate cancer condition found. Liver function testing not paid for since liver is functioning properly. How are we to know if we have a medical condition related to high cholesterol if we don't monitor cholesterol levels?

 

As for your statement that this is the way it has always been, you may be correct for some insurance companies and some policies. However, not so for all. I had a true preventive medicine policy which paid for all routine testing for many years before I went on Medicare, which does not.

 

As an aside, I find it interesting that you were involved in billing as a nurse. I'm not doubting you, it's just that most of the doctors I've visited in recent years had one nurse and about 18 billing clerks trying to sort through the paperwork. :)

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United Health Care can be very difficult to deal with. We have had numerous problems getting them to pay. Recently I went to the UHC website and logged in. It stated the shingles vaccine was 100% covered. I went to Wall Greens and they also checked to see if it was covered. They also received a message from UHC that it was 100% covered. I received the vaccine but a couple of months later I received a bill for the entire cost of the vaccine. I appealed this but UHC stated not covered and coverage is denied. I had to pay the bill. I asked how to know what is covered and was told I could go to the website! A few years ago I received a bill for out of network medical care for $18,000. This was my part of the bill. I argued with UHC for 18 months. As they would review it they kept finding small items that they should have paid. Finally my portion of the bill was reduced to $4000. What a racket!

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Up until this year, we had United Health Care as our Medicare provider (under AARP). We both have had Annual Wellness Exams (including in 2014) with blood tests and, for me, a mammogram. We haven't had to pay anything for either the blood tests or the mammogram.

 

Now, that's under Medicare...I don't know about non-Medicare insurance which you indicate is what you're fighting with since you were not on Medicare when the 2014 blood draw was done.

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It stated the shingles vaccine was 100% covered. I went to Wall Greens and they also checked to see if it was covered. They also received a message from UHC that it was 100% covered. I received the vaccine but a couple of months later I received a bill for the entire cost of the vaccine. I appealed this but UHC stated not covered and coverage is denied.

 

Here's our story about receiving the shingles vaccine (using United Health Care's Advantage Plan):

 

I called United Health Care before receiving my shingles vaccine to find out what the deductible was. I was informed that it was $90-some dollars (NOT 100% coverage). So I went to Safeway's pharmacy to have the vaccine. I paid them the $90-some dollars and they took care of filing the paperwork for the remaining amount with my Medicare insurance.

 

DH had the shingles vaccine done at his doctor's office. We later received a bill for the entire amount of the vaccine (some $200+ dollars). In inquiring why he was being charged the entire amount rather than the $90-some deductible, I found out that the shingles vaccine has to be coded as a Part D expense. Safeway did it that way, but DH's doctor's office was not able to submit it under Part D (I still don't understand why a doctor's office can't submit something under Part D). We went around and around with the doctor's office and did finally receive a refund from them, but it was a learning experience.

 

Now, anytime a doctor wants to give us a vaccine, I always inquire about how it's going to be coded and I'll check with the insurance company to see if it has to be submitted under Part D. If so, I'll go to a pharmacy to have it done, not at the doctor's office.

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Was your blood work done while you were covered under Medicare??

...

I encountered this many times for years doing medical billing as a nurse for a family Dr.

 

No, all the billing questions occurred under UHC. I don't want to criticize them too much, as they did well in sticking with the 15 month appeal process over a $440 bill.

 

I see you are experienced as a Nurse, and medical billing. That does give you considerable background in this confusing area... I worked with the Patient Accounts (Billing) Department for a large Hospital for years (computer support). Very complicated area. You have my admiration!

 

Also, my wife has used the same Doctor for 35 years... and myself for 25 years... and the exams incorrectly coded were (as far as we can tell) the same as previous years.

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I"m afraid you are correct. However, it is a contradiction. The entire purpose of preventive medicine is to discover a medical condition before it is advanced so that it can be treated. This is the principle of preventive medicine which proponents claim will ultimately reduce the overall cost of medical care. And, this was a major selling point of the ACA that even the lowest level policies would cover preventive medicine.

 

 

 

"As for your statement that this is the way it has always been, you may be correct for some insurance companies and some policies. However, not so for all. I had a true preventive medicine policy which paid for all routine testing for many years before I went on Medicare, which does not."

 

My apologizez. I meant to state that Medicare has been this way for years

 

"As an aside, I find it interesting that you were involved in billing as a nurse. I'm not doubting you, it's just that most of the doctors I've visited in recent years had one nurse and about 18 billing clerks trying to sort through the paperwork. :)"

 

My experience involved being the staff manager for a single Dr family practice. One of my responsibilities was our coding/ billing practices and being involved in reviewing for quality control. All reviews and appeals came across my desk on their way to our Dr who prided himself on accurate billing policy and being an advocate for his patients. As a result I fielded many a phone call from upset patients whose coverage was denied for any reason.

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Prior to the ACA, I do not believe there was any standard requirement for annual wellness coverage and if offered in a policy, what was covered and what was not was up to the insurance company depending on the specific policy.

 

 

My experience over the years was that I had 'wellness coverage' covered as far back as I can remember. When we shifted to United Health Care, our understanding was that normal, routine tests were covered. And the Customer Service Reps stated several times, that the ACA had changed what was covered as part of an annual exam.

 

Frankly, I am still confused over the whole thing. Glad I am on Medicare. My wife has 18 months to go yet. And just for grins... back in November 2014, when I asked UHC what it was going to cost for just my wife to continue with UHC... I received four (4) different quotes within four weeks. The variation was about 30%. Of course the highest quote prevailed.

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Now, that's under Medicare...I don't know about non-Medicare insurance which you indicate is what you're fighting with since you were not on Medicare when the 2014 blood draw was done.

 

Yea, Linda, this all occurred under a private policy with United Health Care. So far, I am finding medicare much easier to navigate... but my wife is still with UHC. One of the things I have learned, is to ask about codes BEFORE incurring the cost. Thanks have changed.

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A few years ago I received a bill for out of network medical care for $18,000. This was my part of the bill. I argued with UHC for 18 months. As they would review it they kept finding small items that they should have paid. Finally my portion of the bill was reduced to $4000. What a racket!

 

Randy, I used to be skeptical of these type claims... but a part of me thinks that is what may have happened to me with my appeals. That is partly why I am wondering what others have experienced.

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Now, anytime a doctor wants to give us a vaccine, I always inquire about how it's going to be coded and I'll check with the insurance company to see if it has to be submitted under Part D. If so, I'll go to a pharmacy to have it done, not at the doctor's office.

 

This is a good idea anytime you have a procedure that you have not had done before. I ended up paying for eye exams simply because of the coding. When I talked to the billing department I was told I need BETTER insurance.

 

My insurance company ALWAYS goes by the CODE in determining payment. So the change has to originate with the service provider.

Edited by Vladimir

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My insurance company ALWAYS goes by the CODE in determining payment. So the change has to originate with the service provider.

 

Vladimir, you have a very good point here. In my 15 month appeal with United Health Care, they initially claimed that the blood tests were coded NOT as wellness, and would direct me to the service provider. This happened to include the blood-draw facility (local Hospital clinic) who pointed me back to my Doctor as the requesting source. I went thru this iteration twice before tossing in the towel, paying the bill, and then filing a formal appeal. The blood-draw facility was confused, as was my long time Doctor.

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