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									                                                     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
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      
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,
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,
•        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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