The Affordable Care Act, also known as Obamacare, has been limping along lately, with this puzzle still missing key pieces.
But an important part of Obamacare is already here, and you can -- and should -- take advantage: The right to have free preventive health care. It only works, however, if your doctor understands his or her part in the claims process. These screenings include mammograms and colonoscopies.
In addition, other preventive screenings may not carry a copayment, co-insurance or deductible. This includes screening for blood pressure, cholesterol, cancer depression and many others.
But this doesn't stop doctors' offices from miscoding and turning your routine screening into a diagnostic procedure for insurance purposes. And guess what? Diagnostic visits do have copays or co-insurance.
My wife's eye exam was supposed to be a routine screening. Her health insurance entitles her to one every two years. So she called and made an appointment. But when she read her health insurer's Explanation of Benefits (EOB) after the exam, it said that she owed nearly $100 -- the difference between her doctor's contracted rate with the insurer and her doctor's price for the office visit.
So she called her insurance company to find out why she had been billed for a screening, which was supposed to be free. Her insurer said that it wasn't a screening but a diagnostic visit, and therefore she'd have to pay her portion.
"How did this screening become a diagnostic visit?" she asked.
It's all in the coding, the insurer told her. The doctor's office used the letters Dx to explain the finding instead of the letter V to indicate a screening. If the office resubmitted the form with the proper V code then she wouldn't owe any money.
Medical billing to blame
My wife's next call was to her eye doctor's office to straighten out the billing error. The office told her that when the doctor wrote down his findings on her chart, the office billed the visit as diagnostic instead of a screening. She asked why it would submit the claim that way and was told that his finding indicated a problem which she and the doctor had talked about.
The problem with the problem: It wasn't new; it was minor, and had already been discussed previously. So this was a screening after all.
She told the doctor's office that her health insurance company would pay the claim in full if it was resubmitted with the right coding. And she told the person she spoke to that she wouldn't discuss this finding with the doctor in two years -- when she was entitled to her next screening -- and would end the conversation if he started it.
Getting your Obamacare wellness services
Here's what you need to know about Obamacare's "wellness" services:
- The most important annual screening is a yearly physical.
- Keep track of what screening tests you had and when.
- Make sure your appointment is specified as a screening.
- You don't pay for screenings, but you do pay for diagnostic visits.
- Doctors' offices miscode and insurers don't know if it's right or wrong.
- Read your EOB to make sure it conforms with the reason for your doctor's visit. If it isn't coded as a screening (V code) but instead as a diagnostic procedure (Dx code), call the office and ask the billing department to resubmit the claim with the proper coding.
Above all, remember that you have the right to stay healthy, and insurance-covered screenings are an important part of the process.