Preventive Exam Policy

 Routine Preventive Exams/Annual Physicals

Many insurance companies and employers are placing a renewed emphasis on wellness and preventive care. As a result, there is a trend toward plans offering a yearly preventive exam at 100% coverage (not subject to deductibles, coinsurance, and copayments). Here are the facts you need to know regarding preventive exams.

Q: What is the purpose of a routine preventive exam/annual physical?

The purpose of a routine preventive exam is to identify potential health problems in the early stages when they may be easier and less costly to treat (such as hypertension, diabetes, or elevated cholesterol).

Q: What is involved in a routine preventive exam?

A routine preventive exam usually includes the following: a review of any intervening medical history (anything that has changed since your last visit); vital sign evaluation and review of body systems; review of medications; immunizations; counseling on risk factor reduction; review of age/gender-appropriate screening tests; laboratory exams such as cholesterol or diabetes screening. The exam is prevention-focused, not problem-focused (see below).

Q: Why did I receive a bill after my routine preventive exam when it was supposed to be covered at 100%?

This exam is prevention-focused, not problem-focused. Therefore, if you have a health problem that needs to be addressed during your preventive office visit (high blood pressure, headache, diabetes, rash, etc), part of the exam may be billed for diagnosis and treatment of that condition. The portion of your visit related to the treatment of your problem would be subject to deductibles and coinsurance, just like any other problem-focused office visit.

Q: Will the doctor address only what my health plan covers for a preventive exam?

We see patients with a LOT of different insurance plans during the day. The doctor does not know your specific benefits. You are responsible for knowing what services are covered under your plan.

Q: What can I do to make sure I receive my 100%-coverage, routine preventive benefit?

You can take the following steps to help ensure your routine exam is billed correctly:

  1. When scheduling, let the scheduler know that you expect this to be a 100%-coverage annual preventive exam. Vague terms such as “physical” and “check-up” can imply simple follow up on a known health problem, and mean different things to different people. (For example, some women will mean “annual Pap smear” when they say “annual exam,” so let us know if you believe you will need a Pap smear or blood draw.)
  2. When you are in the room to see the doctor, let her know that you are here for a routine preventive exam.
  3. If you bring up a problem during the exam, understand that you may have a charge related to the treatment of that problem.
  4. Do not save up all your health concerns for your routine exam.

You can download a PDF copy of this policy for your records here.