Your Yearly Exam

What it is and what it isn’t

Each year insurance companies pay for your yearly exam, typically with no out of pocket cost to you. This exam is preventative in nature and is a review of your overall health that includes a chest/breast exam, pelvic exam, and pap smear if necessary. The coding for an annual exam is a preventative code.

Problem visits directly discuss a specific medical problem, concern, or question or require and prescription refill or change, and these are coded as office visits, requiring a different and separate code from what the annual exam uses. Medical providers are not allowed by insurance companies to bill a preventative code for a problem visit. If a problem is brought up during a preventative visit the medical provider must add an office visit code to the preventative exam in order to remain compliant with insurance laws. When this happens, some insurance companies will not pay for the office visit and if they do, the copay, coinsurance, and deductible will apply. 

We always try to schedule yearly visits and problem visits separately due to this billing rule to help reduce unexpected out-of-pocket costs for our patients.

Health care providers are required by law to bill insurance for all services rendered. If a patient comes in for a yearly exam and brings up a problem, the provider must bill for both services. If they do not bill for both services it is considered fraud. Both overbilling (billing for a service that was not done), and under billing (not billing for a service performed), are types of fraud and are illegal. If a healthcare provider is audited by an insurance company and they find the provider has overbilled or underbilled services the provider can be fined.

If you have any questions about this rule, please feel free to reach out any time.

Thank you!

~Your WHC Team