One free visit, then a bill

Steve Kuo moved to West Virginia and signed up for a new insurance plan costing five hundred dollars a month. He scheduled his free preventive visit but was billed twice: once for prevention, once as a sick visit after mentioning prior kidney problems.

“No copayment means no copayment, exactly as stated in the insurance guidelines.”

Surprise bills are widespread

On Reddit, more than a dozen people reported surprise bills for preventive visits in the past year. One woman received a nearly one thousand dollar bill for a gynecology visit. Another faced roughly three thousand dollars in charges after an ultrasound and out-of-network lab work.

What the law promised

The Affordable Care Act made it law in twenty ten that Americans get one free annual preventive visit yearly, no matter their health insurance. The visit covers vaccinations, cancer screenings, and cardiovascular health screenings to prevent future health problems.

The cost of confusion

More than fifteen years later, people across the country walk into their doctor's office expecting a free visit and walk out billed for sick visits, blood labs, and more. Researchers estimate Americans spend tens of millions, maybe hundreds of millions of dollars yearly on services supposed to be free.

Doctors see it every day

Dr. Yalda Jabbarpour, a family physician in the Washington, DC, area and medical director of the Robert Graham Center for Policy Studies, says the confusion comes up with patients constantly. She blames the system, not patients or physicians.

“Every single time I'm in the clinic, this issue comes up with a patient. And it's sad that it comes up.”

The law left it undefined

The Affordable Care Act mandated insurers cover preventive services but did not define what parameters that visit actually included. Alex Hoagland, a healthcare economist at the University of Toronto, says the law did not establish clear definitions of diagnosis codes, procedure codes, or frequency.

“They don't define what actually is preventive care and what's not.”

Each insurer makes its own rules

With no clear definition, each insurer defined preventive visits on their own. Preventive visits should be strictly for screenings and preventive measures, but you may get billed for an office visit or sick visit if you discuss any specific symptom you are experiencing.

Mismatched incentives

Insurers want to keep preventive care definitions narrow to pay fewer claims. Doctors want payment for actual services provided. Alex Hoagland says this is not corporate greed or physician incompetence but a natural mismatch of incentives in the fee-for-service system.

“It's just a natural mismatch of incentives.”

One visit becomes many bills

In fee-for-service healthcare, providers bill for each specific thing they do. Your vaccination may be free, but asking about back pain is not. Blood tests are another line item. Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University, explains multiple different things happen during one visit.

“It's multiple different things that are happening when you go into a doctor's office.”

Patients bring everything to one visit

Having just one free visit may lead people to bring a laundry list of questions because they think of it as their only chance to ask everything. This makes it easy for the discussion to tip over into a sick visit, triggering a surprise bill.

Prevention gets crowded out

When patients bring up every health issue at their annual visit, it can take up the entire appointment. Dr. Jabbarpour says they leave without doing screenings, vaccinations, cancer screenings, and cardiovascular risk screening that the visit was supposed to focus on.

“They leave, and it's like, 'Oh my god, we forgot to do all the screening things.'”

Hundreds of millions in charges

A twenty twenty-one study by Alex Hoagland and Paul Shafer, both of Boston University at the time, estimated that Americans with employer-sponsored insurance paid between seventy five million and two hundred nineteen million dollars in twenty eighteen alone for services that should have been free.

Chronic conditions trigger charges

People with chronic conditions are more likely to be charged for preventive care. Alex Hoagland was billed for preventive visits because he has type one diabetes and the system automatically categorized his appointment as a diabetic visit, not preventive.

Colonoscopies show the problem

Colonoscopies illustrate how the fuzzy line between prevention and treatment plays out. A patient goes in for a preventive colonoscopy, but the doctor finds and removes a polyp. The patient then gets billed thousands of dollars because the procedure is no longer preventive.

“Colonoscopies can be thousands of dollars.”

Georgetown proposes three visits

Sabrina Corlette's team at Georgetown University released a proposal that Americans be entitled to three primary care and two urgent care visits yearly with no cost-sharing. This gives people real value from their insurance and should improve population health in the long term.

“We wanted people to feel like they're getting good value, and we wanted to get to better population health.”

What you can do now

Doctor offices should be transparent about what triggers charges. Ask when you schedule your appointment or when they call to confirm. Ask your provider what they consider preventive care when your visit begins. Check your insurer's website or the KFF database for what services should be free.

Establish boundaries upfront

Ask your doctor directly what they consider preventive care and establish boundaries at the start of your visit. That way you can be aware if you will get charged because the conversation crossed the line to discussing an active health problem.

“What do you consider to be preventive care?”

Push for systemic change

If you want the underlying laws to change, contact your state and federal representatives and ask what they are doing to ensure this stops happening. Dr. Jabbarpour hopes for a system where doctors and patients can manage health according to particular needs rather than worry about billing.

“To put all patients in the same box and say you can only see your primary care physician once a year if you want it paid for, it makes zero sense.”