My FREE Annual Check-up for $1,347.36

[Logan5]

Dear folks,

I would like to share the story of free annual check-up that would end up costing me $1,347.36.

Since I am a legal alien, I have very little knowledge about how the American health care system works and I would kindly seek your advice on how to proceed farther. It is worth noting that I am insured under my wife's health plan. I do not contribute to it financially, I am a pure beneficiary.

On June 30th, I went to my in-network primary physician for my annual check-up which my health care provider Aetna said they would cover 100%. Part of the annual check-up is a routine chest x-ray, as well.

Let's begin with the x-ray. I told my doctor about this circumstance but he said that he has never heard of a routine chest x-ray, and, in order to get the x-ray done, I would need a condition that justifies the examination. He went on and filed the x-ray under the appropriate code (dry coughing) which would end up costing me $275.19 after insurance. After explaining to him that this is not at all what I wanted or expected, he said he would not know how else to claim it and Aetna would not disclose to him which other code he should use. Luckily, I could convince Aetna to reverse the claim and file it under the same code as the annual check-up. Hopefully i will receive notice about the reversed claim in the next couple of days. So far, so good. I hope you got a first look at my doctor.

During my annual check-up examination, however, my doctor asked me about my past illnesses. I explained to him that I suffered from GERD and a liver inflammation last year and asked him to physically check my abdomen to see if he can find anything unusual. After all, I thought, this is a check-up, right? He did so and found that I showed a positive Murphy's sign and hence suspected I would be suffering from gall bladder stones. I expressed my doubts and explained that I had no other symptoms whatsoever and that I had received a thorough ultra-sound of my inner organs just six months prior to the check-up (due to the liver inflammation).
In this regard, I asked him how much the ultra-sound he suggested would cost me. He said it would not cost me anything because it is a medically necessary follow-up examination and the insurance would cover it. Without investigating how unlikely gall bladder stones were at this point in time, or that the Murphy's sign does not necessarily meant I would have developed any, I thought there is no harm in getting an ultra-sound, just to be sure. I got an ultra-sound at the Alta Bates Medical Center in Berkeley, two days later. They did not find anything. Now, however, I am asked to pay $1,017.59 out of pocket for it.
The insurance said that I have not met my $2,500 deductibles and that is why the hospital billed me for it. That is, whereas I was under the impression the examination would be covered by the annual check-up. After all, what good is an annual check-up when your doctor tells you that you "have something" but cannot confirm that or even tell you what it is…

I spoke to the doctor about it and he said I "would be very unfortunate" but there is nothing he can do. I asked if he could re-file the claim under a different code so that Aetna is satisfied seeing it was a (for him) necessary examination which I did not even ask for and probably would not have needed. He declined and said the hospital is, more or less, just a contractor and my finances are not their concern.

Now, I am stuck with $1,017.59 for a pointless ultra-sound + $54.85 consultation fee. Yes, the doctor billed me, on top of the annual check-up which is covered by Aetna, another consultation fee. Unnecessary to say, he never informed me about that and never told me when this annual check-up became a consultation.

Obviously, Aetna does not want to deal with it and neither does the doctor. While I am still looking for work (employment authorization takes time), I do not have the funds to pay this fee and frankly, I don't see why I should. I only wanted a check-up.

If you have similar experiences or some advice on how to handle this situation best so that I can take my head out of the American Health Care Trap, I would really appreciate it.

 

[unic.consulting]

First, I have never heard of an insurance company covering an X-ray as part of a routine physical (other than dental X-rays at your dentist), so I'm not sure where you got that from. Since you asked for the X-ray, he had to find a diagnosis that could be used. Even if an exam is done at the same time as the routine physical, if it's not part of the physical, there will be a charge to it.

The most common example I have is an EKG. If your doctor listens to your heart during your physical and doesn't like what he hears, he will ask you to do an EKG. This is not part of a physical, so your insurance company will charge you a copay for it. Think of it as having two appointments at once so you don't have to come back to the office again.

The routine physical is covered so people are more willing to go to their doctor once a year so any issues can be found early when they are more treatable (and less expensive). Nothing is treated during the physical. Any treatments you receive are beyond the scope of the physical.

Now that being said, there are a couple of things I would have done differently if I had been your doctor. You say you mentioned to him that you had an ultrasound done 6 months prior. Did he have a copy of that report? If he didn't, I would think he should have received that before scheduling you for another one. Second, he shouldn't have told you their would be no charge for the test. No doctor's office knows every plan out there. To find out the fee, you should have called Aetna before you had the test. Third, what was the consultation fee for? Did he go over the results of the tests with you in his office? If so, that might make sense. Make sure you have the explanation of benefits from your insurance and see if he did everything he charged you for.

As for your plan. With a $2,500 deductible, it's possible it's an HSA plan. Is this the case? If so, do you have an HSA account set up?

No matter what, I'm sorry to tell you, you do owe the money. Talk to the billing department of the hospital and set up a payment plan with them.

 

[Logan5]

Like I said, I called Aetna ahead of my physical to ask about it and they said I would have a routine chest x-ray covered. After talking to an Aetna agent on the phone yesterday, regarding the issue why it was billed to me, he confirmed that it should have been covered 100% by them and I will not have to cover the fees for it. So, believe it or not, but my plan actually includes a free annual chest x-ray

I understand what you said about not having to come back for a second appointment and thus the annual and the exam were conducted at the same time. I find it wrong though, considering the liberties of all parties, e.g. to charge whatever they want for an exam and in return, I can go to the physician I choose, that he did not tell me this was going to be more than just an annual physical. I could have gone to a cheaper doctor and, obviously after suggesting a second ultra-sound, to a cheaper hospital/imaging center. But as I said, I didn't know of any of this. It is the first time I even have to consider all these factors (in my country we have universal healthcare).

He did not have a copy of the report. Come to think of it, it was pretty unlikely that I had developed gall bladder stones and he should have known that. And no, he did not go over any results with me. After he received the radiologist's report, he sent me a sheet saying I don't have anything.

My plan is PPO. Is there no chance for me to argue that the doctor issued tests I didn't need in a place that is unnecessarily expensive? I looked it up, an abdominal ultra-sound is $250-340 on average. How is it that Alta Bates just wants four times that much!?

 

[Quotebroker]

I agree with Unic in general.

In this regard, I asked him how much the ultra-sound he suggested would cost me. He said it would not cost me anything because it is a medically necessary follow-up examination and the insurance would cover it.

This is the biggest mistake in your post. The doctor absolutely misled you here.

 

[rayluk]

Folks,

This is what drives up health care and medical insurance cost. I never heard of a routine chested x-ray for two reasons. 1, If you need an x-ray, you better have a darn good reason for it. 2, how much do you enjoy being exposed to radiation, really?

Even if it is included with the check up. It does not mean you should do it just because it is included. Unnecessary treatment is bad for you and your wallet. Driving up health care cost in terms hurt everyone's wallet.

Welcome to CA.

 

[HealthGuy]

Brother Logan: Its this simple - when you go in for an annual checkup - mention nothing else regarding ANY health problems AND/OR dont let them do anything other than a physical...NOTHING else is considered preventative...If you mention anything else or do anything else, it can throw off the entire visit...Its as simple as that. Get a physical and while you are in there keep your mouth shut. The Dr. would rather bill Aetna for a diagnostic visit so they can make more money - and it happens all the time. Docs are not your friends they have you into their office to make money.

 

[maxherr]

Now, however, I am asked to pay $1,017.59 out of pocket for it.
The insurance said that I have not met my $2,500 deductibles and that is why the hospital billed me for it. That is, whereas I was under the impression the examination would be covered by the annual check-up.

There are a couple of issues you need to consider. First, and foremost, physicians do not understand health insurance any better than you, and most other persons, do. All the physician knows is that he sees patients, his staff submits coded charges, and he gets paid. Ask him if he knows whether his payments are proper or not, and his answer is probably going to be, "I have no idea."

Second, health care is not FREE. The PPACA offers "wellness" and "preventive" health care services with no cost sharing, but that does not make them free. X-rays, ultrasound exams, laboratory services, etc. are DIAGNOSTIC procedures, not preventive health care services. As a result, people actually have to pay for those things.

If your health insurance plan includes a deductible, that is your total "First Dollar" expense paid out-of-pocket for covered medical expenses. Until you have paid that much, your health insurance company has no other responsibility to pay those claims. You obviously don't understand this mechanism, which is not entirely your fault. Obama and the Democrats led you and millions of others like you to believe health care was not going to cost you much money. If I, as a licensed insurance agent, were to do the same thing, you could sue me for MISREPRESENTATION, and would win your case. But you cannot sue the President or the Democrats.

If you don't understand how your health insurance works, you should talk to a licensed agent who can help you learn what you need to know. You can write or call me. Use the link below to my website for contact information.

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I could have gone to a cheaper doctor and, obviously after suggesting a second ultra-sound, to a cheaper hospital/imaging center.

You might think this is so, but unless you stay within your PPO network, you are highly unlikely to find a "cheaper hospital/imaging center". And when it comes to finding a "cheaper doctor", consider this: If you needed brain surgery, would you want it done by the guy who charges the least amount of money or by the surgeon who has the most experience? With experience comes commensurate fees for services rendered.

Price is only an issue in the absence of value.

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My plan is PPO. Is there no chance for me to argue that the doctor issued tests I didn't need in a place that is unnecessarily expensive? I looked it up, an abdominal ultra-sound is $250-340 on average. How is it that Alta Bates just wants four times that much!?

Is "Alta Bates" one of your PPO network providers? Probably not. If it were, your charges would have been contract-limited.

Then again, you may have a "prior notice" requirement to alert your insurance company that you are about to undergo a diagnostic procedure. Several years ago, my wife's group plan changed and this was a requirement I failed to notice in the plan information. When I needed an MRI, what should have been a $30 copay ended up being $70 because I did not provide prior notice as required. I only made that mistake one time. It was my fault . . . entirely.