Office Visit Categories and Costs Vary

We want to help you understand how insurance companies define office visits and help you expect what your out-of-pocket expenses might be. Knowing ahead of time what type of exam a patient needs helps the office staff assign appropriate time and resources for their appointment.

Please keep in mind that once you are in with the doctor, your visit category may change. For instance, you may schedule a preventive visit but, during the visit things change and the doctor ends up evaluating or treating a health issue. The specific charge could change from the original intention of the visit.

There are two main categories for doctor visits. The first is called E&M (evaluation and management) and is when you need treatment for an active disease such as the flu, ear ache, bladder infection, diabetes or high blood pressure.

The second type is a preventive visit, also called a physical or checkup. This type of visit screens for unidentified illnesses and can include counseling by the doctor to encourage a healthy lifestyle to prevent future disease.

Evaluation and Management Visits (E&M)

Whether you see the doctor for a limited medical problem or for a complex range of problems, your visit requires doctor evaluation and management of your issues. The doctor will ask you about your symptoms, changes since your last visit, and determine the next steps for your treatment.

Examples of E&M visits include:

• Illness visits or follow up to an illness visit
• Management of existing chronic diseases (like diabetes) and medicine refills
• Emergency or urgent care follow up
• Follow up after hospitalization
• Pre-operative clearance exam

Preventive Visits

Preventive visits, or a physical or check-up, screen for disease or sickness and promote healthy living. Often, when a patient calls and asks to get “established” with a doctor or wants a “physical”, the staff will schedule the patient for a preventive visit.

Depending on a patient’s age and gender, a preventive visit may include:

• Screening tests
  • Blood pressure
  • Cholesterol
  • Obesity evaluation
  • Diabetes Type II screening
  • Depression screening
  • Alcohol misuse
  • Pap test
  • Mammogram
  • Sexually transmitted disease, if at high risk
   
• Immunization evaluation and updates 
• Counseling for healthy lifestyle changes

Examples of Preventive visits include:

• Preventive visit (check up) with/without an annual gynecological exam
• Pre-employment physical
• Well-child checkup (school, camp, or sports physicals)

For both E&M and preventive care visits, certain services and tests may carry a separate charge and potentially an additional physician charge (other than your primary care doctor) for reading or interpretation is possible.

What Kind of Visit Does My Insurance Cover?

Your doctor’s office is part of Premier HealthNet and we routinely file claims as a courtesy to our patients. The billing staff also follows up to make sure the insurance company has received the claim. We can’t predict how your insurance will pay for your services because benefits vary greatly. We recommend contacting your insurance company before your visit.

Health insurance is a contracted relationship between you and your health insurance company. Therefore, when there are delays in payment from your health plan, you may receive a statement from your office. Sometimes additional information is needed from you to process the claim. Please call your insurance company regarding the non-payment before calling our billing office. 

Also, some insurance companies have reduced benefits for mental health treatment. If you need to be seen for depression, anxiety, or have other mental health needs, talk to your insurance company to avoid surprises later.

When you call to schedule an appointment, it is helpful to give the receptionist the following information:

1. The type of visit you want.
2. Whether you are sick. The office will get you in as soon as possible.
3. If you have no illnesses, but want screenings and discussion about healthy lifestyle changes, you need a preventive exam.
4. If you are requesting a preventive visit, be sure enough time has passed since your last preventive visit (often, this is one year) to be covered by your health plan.
5. How you will pay for services not covered by your health plan.