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Wellness Visits vs Problem Visits

In this article we hope to explain the difference between an annual exam, also known as a wellness exam, and a visit.

What Is a Wellness Exam?

An annual exam is a comprehensive preventative exam with your primary care provider for the sole purpose of preventative care. An annual exam does not include discussion of new problems, review of chronic conditions. Annual exams may also be called routine check-ups, yearly exams, annual PAPs, or preventative visits.

Will My Insurance Pay for A Wellness Exam?

Most health plans will pay for one preventative exam a year. Most plans will allow you to be seen by your Family medicine provider once a year for wellness and once with your gynecologist.  Your insurance provider may consider this to be once per calendar year or one year and one day since the last wellness.

If you have any other visit billed as preventative during this time period your plan is likely to deny your wellness exam. This would include a well-women exam or annual PAP smears.

Your plan may not pay for all testing or labs ordered during your wellness. If your provider has a concern and orders diagnostic testing and /or labs during your exam you may be held financially responsible. 

It is the patient’s responsibility to check with their insurance provider to see what is covered under their wellness benefits and to ensure they are eligible prior to scheduling their annual exam.

What is the Difference Between a Wellness Exam and a Problem Visit?

Preventative visits and tests ordered by your provider can help you stay healthy and catch problems early. Diagnostic visits and testing are used to diagnose a current health problem. Diagnostic tests are ordered by your provider when you have symptoms and they want to find out why.

More Time and Services Mean Different Billing

Here is a guide to the steps that may lead to a bill or co-pay for your wellness visit:

If you bring up new symptoms, such as indigestion or aching joints, at your wellness visit, the doctor will need to make notes about the conversation and spend additional time with you to explore the symptoms, any needed testing, and possible treatment. This, in turn, may trigger rules that require your doctor’s office to code your visit for billing and insurance purposes in a different way.

Even if your insurance company fully covers an annual wellness visit or physical, you will still be responsible for part of the bill in this situation because you are receiving more than just preventive services.
Likewise, if you need to discuss management of an ongoing health problem that’s already been diagnosed, such as diabetes or high blood pressure, this will also lead to different billing.

Your primary care doctor wants to hear all of your health concerns; just keep in mind this may add time and services to your wellness visit and result in your insurance not fully covering your visit.

Can I have a wellness and a problem visit at the same time?

Yes. If you have a wellness with any complaints/concerns/symptoms/procedure/prescriptions – you will be billed for a wellness AND a problem visit. Problem visits will require a copay at the time of service. If you have just a wellness/preventative – most insurance providers don’t require a copay at the time of visit.