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Avoid Insurance Surprises


Avoid Insurance Surprises: Know What’s Covered in a Wellness Visit



Wellness visits, also called physicals or checkups, are an important part of staying healthy. They provide a time for you and your primary care doctor to focus on preventive care and lifestyle habits, such as diet and exercise that can impact your overall health. Most insurance policies fully cover the cost of a single wellness visit per year, but don’t be confused, that does not mean that all services completed on your wellness visit day will be covered by your insurance. We provide this page to help you avoid insurance surprises in our efforts to educate you on what’s covered in a wellness service and also to provide some examples of what isn’t.

What Is Covered in Sick and Well Visits?

The following explanations outline those items typically covered in each type of visit. Let’s start with the easiest to understand, the Sick or Chronic Condition visit.

  • Sick or Chronic Condition Visits

This is a visit for new symptoms or complaints, or a follow-up on chronic problems, such as diabetes, cholesterol or blood pressure. It could be used to consider a new problem such as elbow pain, sore throat, poison ivy or an endless array of other topics. Nearly all insurance policies will require some cost sharing in these visits and, in high deductible health insurance policies, the contracted and discounted insurance rates for these visits will usually end up being applied to the deductible.

  • Well Visit

A wellness visit, also called an annual physical, annual maintenance visit, complete physical or checkup, is usually provided at no cost to the patient. So long as there are no other sick or chronic care issues addressed, there is usually no copay, no cost sharing and no deductible. In contrast to a sick care visit intended in the evaluation and management of a problem, your wellness service is a preventive visit designed to screen for medical topics while managing none. Your wellness service includes the following:

  • Reviewing vaccinations,
  • Talking about diet and exercise or other lifestyle habits that may influence your health,
  • Discussing any routine screening tests that are recommended for your age, gender, or health history,
  • Reviewing your current medications and updating the medical history to detail any other clinician(s) involved in the ongoing management of your medical topic(s),
  • A general examination* of your vital signs, breathing, reflexes, skin, thyroid, and examination of your ears, nose, and throat. 

Isn’t this the right time to tell the doctor about that pain or problem that I have been having? After all, today’s visit is free! Here’s where it gets confusing.

More Time and Services Mean Different Billing.

If you bring up new symptoms, such as indigestion or aching joints, at your wellness visit, or if some worrisome finding is unexpectedly determined on physical exam or in your labs, your doctor will need to make notes about the conversation, spend additional time with you to consider the signs and symptoms, plan any needed testing, and explore possible treatment options.

This, in turn, will trigger rules that require your doctor’s office to code your visit for billing and insurance purposes in a different way. Your visit has now become a Combination Visit and your insurance company will expect that your medical office should code the visit to appropriately reflect the services rendered.

  • Combination Visit ** (My Sick/Chronic Condition and Well Visit Combined)

This is a combination of a sick or chronic condition evaluation on the date of your wellness visit. If you scheduled your annual exam, but then wanted the doctor to talk to you about a new blood pressure medication for your ongoing high blood pressure, then you would be billed for a combination visit. With this type of visit, your insurance will likely require some cost sharing and you should expect to be responsible for a copayment, co-insurance and/or deductible.

Likewise, if you need to discuss management of a new problem such as a rash, sore throat, or an aching shoulder or if there is some ongoing health problem that’s already been diagnosed, such as kidney stones or thyroid disease in management on this same day, this will also lead to different billing.

In either of these scenarios, even if your insurance company fully covers your annual wellness visit, you will still be responsible for part of the bill in this situation because you will have received more services than those items included for your age and demographic based wellness services.

Where insurance companies commonly audit the billing practices of medical offices and will require training updates for practices that fail to maintain published coding standards, you should expect that your visit will be billed in a way that would pass scrutiny if it were to be held up for review.

It’s Like Home Repair Versus Home Maintenance.

A good analogy to this situation can be found in the maintenance and repair of your house. You may schedule your HVAC consultant to do an annual air conditioning inspection to make sure your system is running safely and ready for the summer weather. However, once they arrive for the maintenance visit, if you ask them to also figure out why the system is making a strange noise, or if their inspection determines that the system isn’t cooling at its best efficiency, your technician will need to spend more time evaluating the unit, to determine the problem at hand and possibly make some repair.

Your primary care doctor wants to hear all of your health concerns; just keep in mind that additional topics will add time and services to the day of your wellness visit resulting in your insurance not fully covering the cost of your visit and leaving some cost-sharing responsibility for you, the patient. Don’t be surprised.

Need to Schedule a Visit? Communicate When You Call.

If it’s time to schedule a visit with the doctor, be sure and tell the receptionist everything you want to cover in your visit so they know how much time to set aside. It will also allow them to tell you ahead of time if your intended visit should be considered a sick visit, a chronic care visit, a wellness visit or a combination visit.

It’s possible that we might not have the time to manage every issue that you have in mind on any one visit. For that reason, you should always plan to start with the most important item on your list and work your way down from there. We are always looking forward to seeing you and in making your visit with us a most pleasant experience.

Please call us today to schedule your appointment.


* This examination component is excluded for Medicare beneficiaries.

** Combination Visits are not offered for new patients.


Joseph R Raccuglia, MD
4251 US Hwy 9 North, Suite 3A
Freehold, NJ 07728
Phone: 732-780-3744
Fax: 732-780-9644

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