Appointments: Rules of Engagement

The rules by which physicians must abide (by contract with the insurance companies) are confusing at best. Insurance companies recognize three things: preventive visits, problem-oriented visits, and procedures. Each company has a rule set regarding which services will be "covered," how often they will be "covered" and how much "covered" really means (ie. deductibles).

In general, a "full physical" is a preventive exam in which we focus on cancer prevention, discussion of heart attack and stroke risk factors, and a head to toe check. Insurance companies will not pay for this as well as covering 2-3 other problems. This is why we do not do "refills" of multiple medications during a "preventive visit."

"Refills" are done during problem-oriented visits. We do our best to cover three chronic illnesses in a single visit, because this is what the insurance company covers. And if we are being thorough, this is all we have time to do in a single visit.

Procedures can be problematic. There are different rules for how these are paid. Some insurance companies will not pay for a visit to evaluate, discuss options, choose to perform a procedure, AND perform the procedure. They require the actual procedure to be on a different day. Then, there is often a separate deductible for procedures. Some people are surprised to learn that something they thought would be completely covered went 100% to deductible. We DO NOT want any patient to be surprised by any fees in any way. However, it takes dilligence on the part of the patient to know what his/her insurance covers.

It is imperative (and expected) that patients are well aware of their benefits as per the contract with their insurance provider. The physicians focus on caring for your illness/condition, so they are the last ones to ask whether your insurance covers a particular visit, procedure, or medication.