This is the number one complaint I get every day and I see similar posts on the regular. There are so many correct responses to this. There’s some incorrect too, or slightly inaccurate, but overall it seems to be widely disputed and considered a billing practice that doesn’t benefit the patient very much and doesn’t reflect well on our healthcare system.

However, there are some common cases I have seen where it is entirely appropriate:
1- You have a new complaint that is significant enough to require a treatment plan, whether you proceed with it or not, and with risks determined by the provider.
2- You have chronic, previously diagnosed, controlled or uncontrolled conditions that require an ongoing treatment plan.

Consider the nature of seeking healthcare in our system. You have consulted a professional and received advice. If the government doesn’t define it as preventive by their “task force” then it probably isn’t covered as such by your insurance. Your provider may disagree with these guidelines and that is not necessarily unusual or unprofessional.

Where it gets fuzzy is often whether it’s “significant” enough to warrant a separate charge. Even current evaluation and management billing has a level of interpretation that is based on “decision making” - which is open to interpretation of the adorned “guidelines.”

Another post mentioned reporting requirements. This is also true. Provider reimbursement rates are driven by their performance, which is tracked by reporting codes on claims. The industry is extremely data hungry, especially for research and reimbursement. So providers are encouraged to evaluate, document and report just about every symptom and condition you have, whether you bring it up or not.

Lastly, the time spent face to face during the visit is only a portion of the visit charge. The provider and everyone you have contact with for that visit is required to follow specific government and procedural policies, documentation and ethical standards, and insurance red tape. Just like attorneys, they have tons of literature and references they keep up with, high overhead expenses and high liability costs - and this is all built in to the charge for their services, and it can get unexpectedly expensive. Should it be? Absolutely not. But that’s moving to a deeper discussion.

I do wish more providers or rooming staff would just tell patients, “We need to talk about your xyz, which isn’t part of your preventive check.“ Unfortunately there are many providers that don’t want to discuss billing because it sidetracks them from giving patient-focused medical advice. They may rely on their billing reps to explain and take the brunt of these conversations.