We realize that it is difficult to navigate the complexities of your insurance coverage, so we have put together this brochure in the hope that it will help clarify some common questions.
It is your responsibility to know what is covered by your individual insurance plan. We are unable to keep track of all the different plans of each insurer. Calling your insurance company before a visit may help you understand what is covered and what is not. We are required by law to bill according to the services that are rendered by your physician, and we cannot alter our billing to get you coverage for things your insurance will not cover.
Here is a glossary of some terms that you may see when reading about your insurance:
Annual Wellness Visit (AWV): This visit type is for Medicare Part B Recipients and some Medicare Replacement Plans only. It is a first attempt by Medicare to start covering preventive services, but it falls short of what many patients expect. In particular, an AWV is not a physical exam. An AWV includes taking a medical history, screening for cognitive impairment, depression, loss of vision or hearing and reviewing medications. Advanced care planning may be discussed, including health care proxies and end of life planning, if appropriate. Screening that is appropriate to your age and gender will be discussed. There is no physical exam during an AWV and most laboratory testing is not covered.
Physical exam: This is covered by most insurers and does not typically require a co-pay. Medicare will only cover a onetime physical performed during the first 12 months that you have Part B coverage. This is called your “Welcome to Medicare” physical. Medicare will NOT cover any other physicals after the first one. During a physical your doctor will review any chronic problems you might have such as high blood pressure or asthma. S/he will also review your medications, drug allergies and family and social histories if applicable. Age and gender-appropriate screening will be discussed. S/he will then perform a physical exam and order appropriate testing. If you have Medicare only and you schedule a physical exam, you will be responsible for the bill. Please note that secondary insurances, such as Medex, will also not cover your physical exam if Medicare denies coverage.
Problem visit: This is a visit to discuss either an acute issue such as fever, rash, difficulty breathing, etc., or a visit to follow up on chronic medical issues like high blood pressure or diabetes. If you have Medicare and have chronic medical problems, this is the type of visit you should be requesting (not AWVs or physicals). Most insurance plans require that you pay a co-pay for this visit type. If an acute issue coincides with your normal physical exam, you may be billed for both the physical AND a problem visit. Likewise, changing the management of your chronic medical regimen such as starting a new drug or changing the dose of another drug are considered “problem” visits and may be billed, even if this is done during your appointment for a physical.
Facility fee: This is a charge billed by hospital-based practices. Brigham Physicians Group (BPG) has a full lab, radiology and endoscopy services on-site and is thus considered a hospital-based practice. A non-hospital-based practice would be a traditional doctor’s office where you would be sent elsewhere for all testing or procedures. A hospital-based practice provides more convenient care for patients by having services on site.
Professional fee: This is the fee for the doctor’s part of the visit and reflects the work done in assessing and managing your medical condition. If you have a physical and also discuss an acute problem, you may be charged two professional fees: one for the preventive work done during the visit, and one for the acute problem.
We wish that these issues were less complex. Unfortunately, some insurers place significant restrictions on what they will pay for and we are bound by that. Ultimately, if you are unhappy with your coverage or costs, changing your insurance may be your only option.
We remain available to help with any questions you might have. Please call your insurance carrier with specific questions about your policy coverage. For specific questions about your BWH bill, please contact Patient Accounts at 617-724-1914.
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