Your “Free” Yearly Physical Is Free Until You Talk About Your Health
This sign was posted in a clinic – your “free” yearly physical is free until you talk about your health. Why does this System work like this?? Glad you asked!
Why the Annual Visit Is Free in the First Place
ACA preventive visits (99381–99397 / wellness codes) are $0 cost-share on purpose. The point was: come in once a year, catch things early, don’t let cost be the reason you skip it. This is already a good thing for insurance companies, because cancer and hospitalizations later on suck and are also expensive (also Insurance tho: “why not double dip and make extra money off the preventative visits too!!”)
Turns out, they can!
The Modifier 25 Technicality
Because CPT states: If anything “significant and separately identifiable” gets addressed in the same encounter (new symptom, old med, a rash the doctor notices, “how’s that med working?”) – you can drop a problem-oriented E/M (99213-style) with modifier 25 on the same day. So this is interpreted as: YOU ONLY HAVE TO DISCUSS IT, not even treat or refer, which follows the LETTER of the rule but maybe not the spirit of it.
Insurance again wins on a technicality: Preventive visit is covered, but THE SECOND CODE: gives the patient a surprise bill. At least the clinic in the photo discloses this so patients can invoke their Fifth Amendment right to not speak about their pain and avoid being charged.
So What Is the Annual Visit Actually For?
Every other visit already takes your vitals. If the annual is not the place to talk about any health concern (new, old, worrisome, or “the doctor asked”)… then what is it? Lab tests? Just go to the lab, but again you are only able to do free preventative things, which are the annual USPSTF-recommended screening labs.
Who Writes the Rulebook
Medical Clinics blame Insurance, and Insurance says they bill what was coded/following the rules. Classic Double Spiderman meme.
The rulebook is called CPT, written and copyrighted by the AMA (a PRIVATE Organization that less than 15% of US docs are members of). CMS and commercial payers adopted it as the standard language of payment; otherwise, we could just tell the AMA “cool story, bro” because they don’t have any political authority on their own.
Where AI Fits Into This
AI’s ambient scribes + autonomous coding sound awesome at conferences and on LinkedIn – “CAPTURE ADDITIONAL REVENUE”, but in real life here’s another example of a layer on top that sucks for the patient. Every person working in the US health Industry will one day be a patient and be at the mercy of the system themselves.
Everyone Becomes a Patient Eventually
There was a finance guy I know who was talking about how much he was making in some specific rural health ventures, shutting down those that weren’t profitable, but when his wife’s prenatal coverage changed and he couldn’t use his fancy NYC doc and had to switch mid-pregnancy and “slum it” with a doc in Jersey, he felt the pain of the system. Still don’t feel bad for him; his wife still got healthcare, unlike the rural folks whose access he cut off.
The Recap
So to recap: Great for capture rate and RCM vendors, but not great for patients (which is ALL of us at some point) who go to an annual check-up thinking it’s the ONE TIME a year (covered by insurance) they were allowed to discuss their health concerns with a professional.