Tips from Paula: Billing for Additional Services During Routine Exams


I get many calls throughout the year from customers who are questioning charges on their bills for annual exams.  As you probably know, an annual exam with your primary care provider (PCP) is covered in full as part of the Affordable Care Act (ACA) guidelines.  What we are now finding out, is that PCP’s are billing for additional charges if something other than routine care is discussed.  For example, a patient may have knee pain, or perhaps a nagging cough, prior to their annual exam.  The patient decides to “hold off” and talk to the doctor about that issue during their physical.

Many PCP offices now bill additional charges when something other than routine care is covered during an annual exam, with an actual diagnosis code.  A patient receives a bill for the time spent talking with and diagnosing the knee pain that was brought up during their annual exam. 

A charge with a diagnosis code may result in cost sharing for the patient, since the insurance company will be applying that diagnosis code to the patient’s deductible.  Therefore, patients should be prepared for a possible bill if something other than routine care is performed at the time of the annual exam.

Please contact me directly with any questions and I am happy to help.  





 Paula Green
 207.523.0065
 pgreen@acadiabenefits.com





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