ACA and wellness visit billing
I met with my PCP for an annual wellness exam. I also met with my gyn for a women’s wellness exam. I thought both were covered as preventive services under the ACA. When I disputed this I received the letter below. Can someone help me determine if I’m incorrect? I don’t require a pap smear due to a hysterectomy but she did a breast exam (what I assumed is part of a women’s yearly exam). No new issues were discussed, only a review of current care I was receiving. I thought by federal law they were required to cover both. I have a Medicare advantage plan but I wouldn’t think that matters. Thanks much!
Letter:
Specific Concerns Raised: • Patient disputes $45 copay. Patient states this was for her well woman exam. She states she was billed a regular office visit.
Results of Review: A comprehensive review of your visit and we confirmed the following: • Per Review: Provider documentation, patient is here to discuss hormone replacement therapy and review of medication. A yearly exam was not done at this visit. Charges are correct.
Conclusion: The review has determined that the charge(s) billed are correct; therefore, the outstanding balance of $45 remains patient responsibility.
Patient has her annual wellness exam with her primary care provider on 6/18/2024. Insurance will only cover one wellness exam every 366 days. If this visit on 9/3/2024 was billed out as a yearly annual exam, insurance would have denied the claim since patient already had one done this year.
submitted by /u/Emotional-Wishbone-5
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