Well Patient vs. Sick Patient


My insurance has told me that I am allowed one free preventive visit per year.  What is included in a preventive visit and why can't I have all my regular yearly tests done at the same time?

Many insurance companies separate preventive, or "well care" visits from "sick care" visits in which the patient is seen for follow-up of established medical problems.  The codes we use to charge for the visits are completely separate, with illness charges related to the duration of time spent and the severity and number of problems, and the preventive care charge related only to the patient's age.

Insurance companies consider heart disease, diabetes, thyroid conditions, high cholesterol, and other medical illnesses to be "sick care", even though you may not feel sick and may be completely healthy on your medications.

Some people have insurance that will cover one yearly preventive visit but will not cover any office visits for treatment of medical conditions.  People who have this type of coverage naturally want to get as much done in their preventive visit as possible.  However, the insurance companies recognize and do not cover tests done for the medical problems.  They are therefore applied to your deductible.

An annual Wellness visit is typically done for someone who is feeling well and has no particular problems.  It does not cover problems requiring additional testing such as severe joint pain, or an acute illness or management of chronic medical problems.  If someone does come in for a preventive exam and has medical problems that need to be addressed, we will typically change the visit to an illness visit or take extra time added to the wellness visit.  In that case, you will be charged a co-pay, not required for Wellness visits.

The preventive visit includes an extensive questionnaire, family history, current medications, any current symptoms and may include a physical exam, including a breast exam and Pap test for women. Medicare Wellness exams do not require a physical exam, but include a memory assessment and gait evaluation.

Covered screening tests include a mammogram for women to screen for breast cancer every 2 years for average risk women 50-75 years old. If there is a personal or family history of breast cancer, yearly exams are recommended. If previous pap tests have been normal, current recommendations are for every 5 years and if normal,stop after 65.  In patients 50-78, some type of screening for colon cancer (yearly stool card or a colonoscopy done every 10 years) is also included. Currently, routine prostate cancer screening is not recommended unless there is a family history of prostate cancer or symptoms.

Screening for osteoporosis in women over 65 is also covered, unless the woman already has osteopenia or osteoporosis, in which case the testing is not covered since it is not a screening test but a follow-up diagnostic test. 

If you have never had a cholesterol test, blood sugar or kidney test done, these screening tests are covered, and if normal, can be repeated in 5 years.  If however, someone is already taking medications for blood pressure, diabetes or high cholesterol, then any tests ordered to follow those conditions would not be considered screening.  Screening means that we are looking for a problem.  If you already have the problem, you don't need to be screened for it.

It is really important for you to know what your insurance will cover before scheduling a well-patient visit or physical exam. Medicare, for instance, will cover a Wellness exam for both men and women once a year, 12 months and 1 day apart. Once a well-patient physical exam has been done, it is not possible to change the charge later to a medical problem-focused exam charge. The charge information that is sent to your insurance company uses completely different service codes for problem-oriented visits versus preventive well-patient visits.