The Annual Well Women Exam includes: Billing for Preventive Services • Comprehensive history and physical: So that insurance carriers and providers “talk Important Information Regarding Your provider will ask you a few questions the same language” when submitting claims for Annual Well Woman Exams about your sexual, medical and family history payment, the health care industry uses a and Insurance Coverage and then will perform a physical exam to system designed by the American Medical check your overall health. Association to report provider services to • Breast exam: Your provider will inspect insurance plans. Each one of the codes in this and palpate your breasts and your underarms system (called Current Procedural while your arms are in various positions. Terminology, or CPT for short) has a specific • Pelvic exam & pap smear: Your provider definition that is universally recognized by will examine your reproductive organs for providers and insurances alike. All insurance problems and check you for cervical cancer. company contracts with our providers, and the • Wellness Counseling: Issues such as diet federal Health Insurance Portability and and exercise, smoking, self breast exam, Accountability Act, August 1996 (HIPAA) menopausal symptoms and hormones. require we adhere to the CPT system. Your health insurance plan may not The “well woman” examination is reported to provide coverage for preventive services. the insurance carrier using the appropriate Many traditional insurance plans only cover preventive visit code that identifies the services The physicians, midwives, nurse practitioners and services to treat known problems or to outlined above for your specific age group. Any staff of OB-GYN of Lancaster value the trust and diagnose a problem when there are other services outside of those identified above, such responsibility you place in us to care for you. We presenting symptoms. Most HMO plans and as laboratory tests, the collection of the pap acknowledge our nation’s healthcare and insurance many PPO and POS plans do cover smear specimen, bone density testing, etc must systems are very complex. This pamphlet is to preventive services. If you have any be reported separately and billed according to help you learn more about the annual well women questions about whether preventive or these industry accepted standards. exam, what may be covered (and what may not be “screening” services are covered under your covered) by your insurance plan when it comes to health insurance plan, we encourage you to What is billed separate from the well women preventive health services. talk with the benefits representative at the exam? employer who provides your insurance • Pap test, the Hemocult test, ultrasound If you have questions, please ask to speak with a coverage or to talk with a customer service imaging, laboratory tests, and dexa scan (bone member of our Business Office or the provider representative at your health plan. density testing) are separate charges. during your exam. Our Business Office may also • There is a separate charge for obtaining be reached at 717-397-7085. What if a service is not a covered benefit? specimens for testing, as well as processing Many insurance plans require the patient to and interpretation of the specimen. The purpose of your physician or other be informed when benefits may not cover a • Provider services related to a problem or provider’s recommendation to have a periodic service. Medicare requires the Advance illness, with further history of the problem, “pap, pelvic and breast exam” is to screen for Beneficiary Notification (or ABN) form to be physical examination, diagnostic testing and/or potential reproductive health problems, including completed prior to the visit. Other insurers treatment as necessary, are billed separately. breast cancer. It is important to have these exams require a documented notice or a Waiver of regularly so that any problems you may have can Financial Liability. We may mail one of We use the latest Pap technology called be treated early when they are easier to cure and these forms to you, or provide one at our Thin Prep & HPV testing. If your insurance have caused less damage. Reception Desk depending on your insurance does not cover these tests, you may be coverage and the services which the responsible for the costs. If you choose not appointment is scheduled for. to use this technology, tell your provider in advance. What happens to the billing if the provider Does this mean I have to pay 2 copays if Why can’t you just include the preventive discovers an abnormality during my exam – or if my insurance plan covers both preventive service in with the “problem-oriented” I also want to talk about another medical and problem-related office visits? services and bill it all to the insurance problem at the same time I’m here for my annual That is a question to ask your insurance carrier with one code? check-up? carrier. Some carriers require that the patient OB-GYN of Lancaster is committed to providing The CPT coding system referred to in the previous pay a portion of each service. Other carriers the highest quality care in a caring, courteous section directs providers and their billing staff on apply the copay to just one service and pay and compassionate way, yet in a cost-effective, this issue. It states, “If an abnormality is their full fee schedule amount on the other. It legal and ethical manner. Intentionally encountered or a pre-existing condition is just depends on what type of insurance misrepresenting the services that were addressed in the process of performing this coverage you have. As a courtesy to our provided to you when billing them to your preventive medicine service, and if the abnormality patients, OB-GYN of Lancaster’s policy is insurance carrier could result in charges to your is significant enough to require the key components to only collect one copay at the time of provider for submitting a false claim against a of a problem-oriented [evaluation] of the patient, your visit, and to bill your insurance for health care benefit program – an action then the appropriate Office/Outpatient code should the other. If your insurance denies coverage recently defined as violation of federal law, as also be reported.” for this, we will assign this to the patient’s amended by HIPAA. responsibility and invoice you. Does that mean I will be charged for two office For more information visit our web site at visits? Paying two copays does not mean the http://www.obgynoflancaster.yourmd.com/ We are legally required to bill the insurance carrier provider gets more money than they would Other credible sources of information about in a manner that represents the services actually have for the same set of services. The women’s health include: provided to you, using the standards of the CPT insurance carrier determines the “reasonable The American College of Obstetricians and coding system. Accordingly, the charges for an and customary” amount to pay the provider. Gynecologists, www.acog.org encounter that includes both “wellness” and If your benefit plan includes a copay, that The US Department of Health and Human “problem-oriented” services must be separated: amount is subtracted from the amount the Services, www.womenshealth.gov • The preventive “wellness” exam, which insurance carrier has agreed to pay the includes a history and other questions related to provider. Copays are not designed to pay the your overall reproductive health and well-being, and physician more, but rather to share the cost of We thank you for choosing our physicians, • The “problem-oriented” exam, with care between the patient and the insurance certified nurse midwives, certified questions related to the history of your problem or plan. registered nurse practitioners and staff as illness, with further physical examination, diagnostic partners for your healthcare needs. As testing or treatment provided, as necessary. always, providing high quality healthcare to While it may not seem fair that your insurance you is and remains our primary purpose. Since there is no single “visit” code that describes carrier requires you to share the costs of both the work the physician or midwife performs when services, one benefit to addressing both your If you have any questions about this he or she does both a preventive service and a annual exam and your medical problem at the information, please feel free to ask your problem oriented service, providers are instructed same time is that it saves you the other provider or call our Business Office at 717-390- to charge two separate “visit” codes (similar to expenses associated with making a separate 7085 for more information. charging for a visit and a procedure when both are trip to the doctor’s office for an evaluation of the problem. performed during the same encounter). The Providers and Staff Generally, the problem oriented service results in a lower level charge than you would have received if the total visit was just focused on the medical problem, since only the additional work for evaluating the problem is counted towards determining what this charge should be.
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