Leadership1 publisher3 min readPublished
Free ACA checkups turn into billed sick visits when patients mention a health problem
Clinics bill free ACA checkups a second time as sick visits when patients raise a health problem, in one case $170 for a mention of back stiffness. The ACA never defined the visit, so each insurer draws that line and patients find it on the bill.
The Board Room · Leadership desk
What happened
- Steve Kuo was billed twice for one clinic appointment, once as his free preventive visit and once as an "office sick visit," after he mentioned past kidney problems.
- On Reddit, a Vox reporter found more than a dozen cases from the past year of people billed for a visit they expected to be free.
- The Affordable Care Act made one free preventive visit a year law in 2010 for most insured Americans, whatever their plan.
- Researchers estimate Americans spend tens of millions, perhaps hundreds of millions, of dollars a year on services the ACA says should be free.
Compiled by The Board RoomSomething wrong?How this is made
Why it matters
- cost The patient pays for the law's missing definition, billed after the premium for a visit the plan presented as free.
- constraint The free visit covers only a narrow conversation, so a patient who brings up an existing condition or depression risks a charge by being candid.
- exposure Lab work drawn during a preventive visit can be sent out of network, putting patients in line for bills far larger than any sick-visit code.
Alex Hoagland, a healthcare economist at the University of Toronto, traces the problem to how the law was drafted [19]. The Affordable Care Act required insurers to cover an annual wellness exam but did not define what that visit includes, he said [11]. "It didn't establish a clear definition of...all the diagnosis codes and procedure codes and how frequently you get that combination within a year," Hoagland said [12]. "They don't define what actually is preventive care and what's not." [13] According to Vox, the gap left each insurer to define the visit on its own, and that is where the perverse incentives start [14].
In practice, the line between free and billed runs through what gets said in the exam room. Vox lists routine vaccinations, many cancer screenings, diabetes and cardiovascular screenings and contraception as topics that should be free to discuss [15]. Chronic pain, prior medical problems and other physical or mental health symptoms, including depression, can lead to a charge, and a first-time patient may also face a "new patient" fee [16]. Kuo's kidney history belongs on the second list [2].
In this reporting, sick-visit coding and the four-figure bills come from different causes. The only sick-visit charge reported with a price was $170, for a brief mention of back stiffness [7]. The roughly $3,000 case followed an ultrasound the patient said she did not request and a blood draw sent to an out-of-network lab [6]. Another woman received a nearly $1,000 bill for what she expected to be a preventive gynecology visit [5].
Kuo pays $500 a month for his plan [1], or $6,000 a year [1]. "No copayment means no copayment, exactly as stated in the insurance guidelines," he told Vox by email. "What is written and agreed upon should be honored." [3]
Physicians run into the same confusion. Yalda Jabbarpour is a family physician in the Washington, DC, area and medical director of the Robert Graham Center for Policy Studies [17]. "Every single time I'm in the clinic, this issue comes up with a patient. And it's sad that it comes up," she said [10]. She does not blame either the patient or the doctor. "In my mind, the blame is not to be put on the patient. The blame is not to be put on the physician. Really, this points to a bigger system issue that we need to solve," Jabbarpour said [18].
These are individual accounts [4]. They do not show how often a mention of a problem becomes a second billing code, or whether some insurers' definitions produce fewer of them.
For a company that sponsors a health plan, the term that decides the bill is the insurer's definition, since the statute supplies none [14]. This quarter's decision is whether that definition is known and explained to the people on the plan before they book the annual visit. If it is not, I'd expect next quarter to bring disputed bills from people who did what the visit seemed to invite and mentioned a health problem, as Kuo did [2].
What to watch
- Federal guidance that defines which diagnosis and procedure codes count as a preventive visit, closing the gap Hoagland describes.
- Claims data showing how often a preventive visit is billed alongside a sick-visit code, and whether the rate differs by insurer.
- A firmer figure behind the researchers' estimate of tens to hundreds of millions of dollars a year paid for services the ACA makes free.