It’s a common scenario – you go to the doctor for your annual physical or wellness checkup, expecting it to be fully covered by insurance with no out-of-pocket costs. After all, yearly well visits are supposed to be free under the Affordable Care Act. But then you get a bill in the mail with multiple copays charged. What gives?
Unfortunately, it is possible for providers to charge copays for both preventive and illness-related services rendered in a single visit. While surprising and frustrating for patients, this practice of “split billing” is allowed under current codes and guidelines.
How Does Split Billing Work?
Split billing refers to a provider billing both a preventive service code and an office visit code for the same appointment. For example:
- Preventive service code: Annual wellness visit (G0438)
- Office visit code: Low-level established patient visit (99213)
The preventive service is meant to cover just the routine wellness check – review of history, vital signs, discussion of screenings, etc. The office visit code accounts for any illness-related complaints or problems addressed during same visit.
So if a patient schedules a well visit but also discusses new symptoms, medications, or an ongoing health issue, the provider may bill both codes, resulting in two copays.
Why Do Providers Split Bill?
There are a few reasons providers engage in split billing:
Maximize revenue – Well visits are meant to be fully covered by insurance. But by billing an office visit code in addition, the provider collects a second copay and higher overall reimbursement. This extra revenue can be significant across their patient population.
Offset rising administrative costs – Providers argue that overhead like staffing, technology, regulatory burden make it necessary to maximize billing opportunities. Split billing may help offset losses and keep their business financially viable.
Discourage excessive sick concerns at well visits – Some contend that split billing disincentivizes patients from turning well visits into full office visits by bringing a laundry list of issues to discuss. It keeps the focus on prevention only.
Compliance with coding guidelines – If a condition is addressed that goes beyond a minor problem, guidelines dictate using an office visit code rather than just the preventive code.
Is Split Billing Appropriate?
Whether split billing is appropriate really depends on the specifics of the visit. In general:
Preventive only – If only routine wellness services were performed, preventive code alone is appropriate. No office visit code should be billed.
Minimal sick concerns – Brief discussion of a minor, stable issue is reasonable at a well visit. Only the preventive code should be used.
Significant sick concerns – If patient presents an urgent issue or new diagnosis requiring physician workup, an office visit code may be warranted in addition to preventive service code.
The American Medical Association (AMA) advises against split billing if the sick concern “is insignificant or trivial and does not require additional work.” So the key factors are the severity of the issue and the amount of additional work it entails.
Unfortunately, there aren’t always clear guidelines on what constitutes “significant” or “additional work.” Providers have leeway in their coding judgement. And patients may feel discussions were basic, while the provider feels it warranted more intense services.
Problems With Split Billing
While permitted in many cases, split billing can create a number of problems:
Patient confusion & frustration – Receiving unexpected bills for preventive services leads to confusion and anger. Damages patient trust.
Over-utilization – Critics argue this practice promotes unnecessary coding of office visits alongside well care. Drives over-testing, referrals, costs.
Obstacle to care – Extra copays deter patients from essential well visits and discussing concerns. Hurts prevention, coordination.
Administrative waste – Contributes to billing documentation requirements, coding overlaps, oversight – increasing costs.
Ethical issues – Violates the spirit, if not the letter, of no-cost preventive care policies. Seen as unethical “upcoding” by some.
Tips for Patients
As a patient, it can feel frustrating and powerless to receive these unexpected copays for your preventive visits. But there are a few things you can try:
Ask ahead – Call your provider to see if discussing any health concerns will lead to an additional charge. Make an informed decision.
Limit sick concerns – Stick to only essential wellness at your visit. Schedule a separate sick visit if needed.
Review EOB codes – If you are billed twice, check the explanation of benefits and codes. Verify accuracy.
Appeal bill – If you feel billing was inappropriate, formally appeal. Cite preventive care policies.
Change providers – Ultimately, you can take your business elsewhere if a practice routinely split bills inappropriately.
The Case for Rethinking Billing
While split billing is technically allowed currently, there are good reasons to rethink this approach:
It undermines policies meant to promote access to preventive care.
It contributes to administrative waste and cost inflation.
It erodes patient trust and satisfaction.
It discourages holistic care coordination.
Many argue it is time to pursue billing reforms that support the spirit of the ACA and value-based, patient-centric care:
Simplify coding – Create a single billing code for total preventive and sick services per visit.
Pursue alternatives – Move away from fee-for-service models that incentivize coding growth.
Focus on appropriateness – Develop better measures of visit complexity to guide billing.
Increase education – Boost patient literacy on billing practices and rights.
In the end, ensuring affordable access to both preventive and sickness care should be the goal. We need a system built on patient trust and appropriate use of limited healthcare resources, not maximizing billing codes. Rethinking outdated billing practices will be key to building a better system.
Frequently Asked Questions
Below are answers to some common questions patients have about split billing:
Can I be charged an office visit copay if I only went for my well visit?
You should not be charged a sick visit copay in addition to your well visit copay if the only services provided were preventive. If you notice two copays on your EOB for a preventive-only visit, appeal the charges.
What if I just briefly mentioned a health issue at my well check?
If it was a minor, stable issue requiring no additional workup at the visit, you should contest the extra office visit copay. Demand coding notes to verify if significant services were actually provided.
When is it appropriate to be charged two copays for one visit?
It would be appropriate if you presented an urgent new problem or uncontrolled condition requiring the physician’s time for diagnosis and management above a routine well check. The sick visit coding should reflect true additional work.
Can I be charged an office visit copay for medication refills at a well visit?
Technically providers can split bill if you discuss medication concerns that require assessment and changes in therapy. But for routine refills, you could argue this is part of overall preventive care and appeal.
What should I do if I think I was inappropriately split billed?
Review your EOB and ask the provider for coding notes. If the additional sick visit code does not appear justified, file an appeal with your insurance company citing preventive care policies. Consider reporting inappropriate billing to regulators.
The Bottom Line
Being charged copays for both wellness and office visit codes at the same appointment can feel like unfair “double dipping.” While permitted, providers should use split billing judiciously based on true complexity. With growing concerns over administrative waste and barriers to care access, the practice warrants greater scrutiny going forward.
Do I have to pay a copay for every doctor visit?
Do you pay copay each visit?
Why was I charged more than my copay?
Can you bill 2 office visits same day?
Can you bill for a copay?