My FREE annual check-up for $1,347.36

My FREE annual check-up for $1,347.36

Posted in the Health Insurance Forum


Oakland, CA

#1 Jul 30, 2014
Dear folks,

I would like to share the story of my free annual check-up that would end up costing me $1,347.36.

On June 30th, I went to my in-network primary physician for my annual check-up which my health care provider Aetna said they would cover 100%. Part of the annual check-up is a routine chest x-ray, as well.

Let's begin with the x-ray. I told my doctor about this circumstance but he said that he has never heard of a routine chest x-ray, and, in order to get the x-ray done, I would need a condition that justifies the examination. He went on and filed the x-ray under the appropriate code (dry coughing) which would end up costing me $275.19 after insurance. After explaining to him that this is not at all what I wanted or expected, he said he would not know how else to claim it and Aetna would not disclose to him which other code he should use. Luckily, I could convince Aetna to reverse the claim and file it under the same code as the annual check-up. Hopefully i will receive notice about the reversed claim in the next couple of days. Bottom line is, that my plan, in fact, covers an annual chest x-ray 100%, believe it or not. So far, so good. I hope you got a first look at my doctor.

During my annual check-up examination, however, my doctor asked me about my past illnesses. I explained to him that I suffered from GERD and a liver inflammation last year and asked him to physically check my abdomen to see if he can find anything unusual. After all, I thought, this is a check-up, right? He did so and found that I showed a positive Murphy's sign and hence suspected I would be suffering from gall bladder stones. I expressed my doubts and explained that I had no other symptoms whatsoever and that I had received a thorough ultra-sound of my inner organs just six months prior to the check-up (due to the liver inflammation).
In this regard, I asked him how much the ultra-sound he suggested would cost me. He said it would not cost me anything because it is a medically necessary follow-up examination and the insurance would cover it. Without investigating how unlikely gall bladder stones were at this point in time, or that the Murphy's sign does not necessarily meant I would have developed any, I thought there is no harm in getting an ultra-sound, just to be sure. I got an ultra-sound at the Alta Bates Medical Center in Berkeley, two days later. They did not find anything. Now, however, I am asked to pay $1,017.59 out of pocket for it.

The insurance said that I have not met my $2,500 deductibles and that is why the hospital billed me for it. That is, whereas I was under the impression the examination would be covered by the annual check-up. After all, what good is an annual check-up when your doctor tells you that you "have something" but cannot confirm that or even tell you what it is…
I spoke to the doctor about it and he said I "would be very unfortunate" but there is nothing he can do. I asked if he could re-file the claim under a different code so that Aetna is satisfied seeing it was a (for him) necessary examination which I did not even ask for and probably would not have needed. He declined and said the hospital is, more or less, just a contractor and my finances are not their concern.

Now, I am stuck with $1,017.59 for a pointless ultra-sound +$54.85 consultation fee. Yes, the doctor billed me, on top of the annual check-up which is covered by Aetna, another consultation fee. Unnecessary to say, he never informed me about that and never told me when this annual check-up became a consultation.

Obviously, Aetna does not want to deal with it and neither does the doctor. While I am still looking for work (employment authorization takes time), I do not have the funds to pay this fee and frankly, I don't see why I should. I only wanted a check-up.
If you have similar experiences or some advice on how to handle this situation best so that I can take my head out of the American Health Care Trap, I would really appreciate it.

“The Skeptical Optimist”

Since: Sep 14


#2 Sep 10, 2014
I understand why you may be distressed by your health insurance coverage.

Even though it is highly-pertinent, a patient can never be sure how a medical service will be billed/coded by the provider or interpreted by the insurer; or if it is correct or in error!

{with BlueCrossBlueShield : For " covered preventative services ",
the service MUST BE coded/billed as "routine/screening" for 100% coverage;
and NOT DIAGNOSTIC or Medical treatment when Co-Pays and Deductibles would be applied.

quite few good reads can be found ...

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