When a Free Check-Up Isn’t Really Free

Unexpected questions can change a free wellness visit into an expensive diagnostic one.

By Kimberly LeonardDec. 10, 2015, at 4:39 p.m.+ More

Patricia Jones thought she was getting the much-talked-about free physical under Obamacare when she went to see a doctor in May. But, she says, a few small things that happened during her checkup ended up making the visit cost more than $450.

First, the doctor asked Jones, who lives in Oregon and describes herself as a full-time mom, if she had moles that were changing colors. When Jones pointed to a spot on her neck, the doctor said it was not even a mole and nothing to worry about.

Then her doctor asked her if she wanted to have a second child, and Jones replied that having one made her tired enough. The doctor said she probably should have a blood test to figure out the cause of her fatigue. 

The doctor also asked whether Jones had any current health problems. She mentioned that she hurt her foot a couple of years ago and that it occasionally bothered her. The doctor looked at her foot, touched it, and took note of it in her medical record.

Later, the bill for the "free" check-up came, leaving her confused and leading to rounds of phone calls with her doctor's office and insurance company. U.S. News confirmed the charges.

Jones, who declined to share her real name because her family's medical records have been hacked in the past, now knows that these questions, along with her answers and possibly other things that happened during what she thought would be her preventive visit, caused it to be billed as a diagnostic one – something her insurance company didn't cover in full as it would for a typical physical.

Stories like this are common among patients, who struggle with confusion about what prevention services insurance covers under President Barack Obama's health care law, the Affordable Care Act. The Obama administration has widely touted the free preventive benefits as a major perk of the law, encouraging Americans to take advantage of them.

"The idea was for patients to no longer avoid getting preventive screenings or checkups because they couldn't pay for them," says Trisha Torrey, founder of the Alliance of Professional Health Advocates. "These kinds of things always have unintended consequences."

Under the law, most health insurance plans must cover a set of preventive services without any cost to patients. Services include vaccines, colonoscopies, mammograms, pap smears, diabetes screenings and tobacco use screenings – all aimed at helping doctors and patients catch problems early, so they don't become costly and more difficult to manage later.

Patients are soon discovering, however, that anything else discussed during a visit with their health care providers could cost them. 

"There are times when a person might be charged cost-sharing for a service that is unrelated to the screening or preventive service, while they are not charged cost-sharing for the screening or preventive service itself," says Jesse Bushman, director of advocacy and government affairs at the American College of Nurse-Midwives.

But doctors don't always tell patients about the possibility of fees up front. And if patients have a bad experience during what they think is a wellness visit, they often then avoid seeing the doctor for similar screenings for fear of high costs – the very thing Obamacare aimed to prevent. "Once burned, twice shy," Torrey explains.

"It took doctors (practice managers and hospitals) no time to figure out that the 'free' part didn't have to impact their income if they could pull out any other little problem that was reimbursable," Torrey said in an email. But doctors, she says, aren't entirely to blame. "This was foisted on them by the government. Doctors are the ones on the front lines who have to explain it to patients."

Dr. Jen Caudle, a family physician and assistant professor at Rowan University in New Jersey, says it happens regularly. "Patients don't know there is a difference, and sometimes we as doctors don't do a good job of explaining that," she says.

Caudle, a spokeswoman for the American Osteopathic Association, shared a hypothetical scenario: If she has an appointment with a middle-aged woman who is getting a mammogram, and the patient begins asking about back pain or having a cough, Caudle will stop the patient and ask whether she wants to discuss those issues during that visit or schedule another appointment, warning her that the other issues may not be covered.

"The problem is that patients are coming in for a physical, but some try to use it as an opportunity to talk about everything that is concerning them about their health," Caudle says.

Clare Krusing, spokeswoman for America's Health Insurance Plans, says patients need to understand what is included as part of their preventive benefits and what questions to ask providers as they are seeking care so they avoid unexpected bills or charges. "People should not assume no cost-sharing with services that go beyond prevention and are actually treatments," she says.

The line between what constitutes wellness or diagnostic visits can be very thin, and insurance companies vary in what they cover. 

Until the Obama administration clarified earlier this year, for instance, that removal of a polyp during a colonoscopy was meant to come at no cost to patients, many Americans who underwent the procedure complained of large medical bills they received after expecting to pay little or nothing.

A colonoscopy, considered a preventive screening, often was being billed as a therapeutic visit when polyps were removed. This occurred even though the purpose of a colonoscopy is for a doctor to check for abnormal growths that might be cancerous – something that can only be evaluated if a doctor removes a polyp for biopsy. Though with other screenings patients might be able to inquire about cost throughout a visit, a colonoscopy requires patients to be given anesthesia, and polyps are discovered half of the time, though most aren't cancerous.

But preventive screening can also cost more for patients when they need it more regularly. Bonnie Jaffe, 49, who lives in Santa Monica, California, tested positive around 2010 for BRAC2, the gene mutation that causes breast and ovarian cancer. She opted to have her ovaries removed, and annually has to have a mammogram and a breast MRI to keep watch on her health. In 2013, she received a bill for about $400 for her breast MRI, which had previously been covered. After calling her insurance provider, she found out the MRI – which is being used as a way to catch any signs of cancer early – was being billed as a diagnostic procedure.

"There is nothing to diagnose," Jaffe says. "I don't have [cancer]. … This is a preventive screening as determined by my doctors. I don't know how this doesn't qualify."

She was billed again for her breast MRIs in 2014 and 2015. . She is appealing the bills, and says she plans to continue the fight. "There are a lot of people who can't pay for this and a lot of people who won't," she says. "They have other things to prioritize like rent or food."