You have made your free annual wellness appointment with your provider. You know it’s been at least 365 days since your last visit to ensure it is covered by insurance. During your visit, your provider reviews your weight, medications, and health events that occurred last year and updates your record. This is what an annual wellness visit covers. You begin to wonder, “should I mention to the doctor about my inability to sleep?”
STOP. If you have new additional needs requiring treatment, it’s time to make another appointment. Why?
This is called a “problem visit” and requires a separate appointment to consult, diagnose and provide a possible treatment plan. If you discuss this during your annual wellness visit, your visit will no longer be free. It turns into the problem visit and will be charged accordingly. So, when you receive your insurance EOB and the Perry bill, it will reflect the problem visit charge and you will ended up asking yourself, “What the heck?”
It’s not that your provider wanted to charge more. In fact, they have nothing to do with the bill that ends up in your mailbox.
Health insurance is becoming difficult for the patient to stay on top of and make wise choices. Here is a behind the scenes detail of what happens after your appointment ends.
Your information including an appointment summary, tests and imaging results are placed in the hands of the medical records department. At Perry, this department is known as the Health Information Management (HIM) services. They weren’t there for your visit, but they are responsible for reviewing what happened during your visit. The team of coders has two major tasks: code your appointment, and review and correct information from your appointment. They are essentially looking at the details of your visit--your discussion with your provider, tests completed, a broken arm casted, anesthesia before surgery, etc. in order to assign an alphanumeric code to each and every item during your visit.
There are tens of thousands of codes set by American Medical Association or Medicare, and all insurance providers recognize these codes. Not all insurance providers cover each code. This is where the process gets tricky. The HIM coders try to identify and match what happened during your visit with what your insurance considers medically necessary.
If it does not pass your insurance’s medical necessity parameters, the company rejects the claim and does not provide authorization. Perry’s HIM team takes a second look at rejected bills needing additional diagnosis.
Below are a few examples.
Certain tests are often covered for individuals with diabetes. However, the test could be coded in different ways, depending on the type of diabetes a person has. A claim coded as “diabetes-unspecified” might be rejected by a certain insurance provider, whereas coding it as “diabetes-type 1” or “diabetes-type2” would pass.
A jaw surgery, completed by a surgeon at a hospital, could be coded as a dental or medical issue. While one of those codes could be covered by an insurance provider, the other might be rejected.
Most often the issue in completing a successful submission is your visit with your provider, lab or imaging testing is missing or non-specific information was used in the notes section. Perry’s HIM coding team frequently works with all departments to clarify what happened during the visit and document correct billing codes.
The world of insurance and medical billing is complex, and unlikely to become more easily navigable in the future. Even after checking with insurance providers in advance, little things—like asking your provider about new pain in your back—can completely change your visit type and the resulting bill.
Rest assured the HIM and business office team work hand in hand to ensure insurance providers get the details needed to ensure you have as much coverage as possible for your visit.
If you have questions or problems with your bills begin with Perry’s financial counselors.
Patient Financial Counselor A to L (815) 876-2067
Patient Financial Counselor M to Z (815) 876-4431
They will help you decipher the why your insurance company did what they did and provide a next step direction for you to fix your problem.