For many patients, a yearly checkup is the only time they see their primary care clinician. It’s an opportunity to check in on overall health, review diet and fitness, have blood drawn for common lab tests, and review any recommended screenings and vaccinations. In recent years, however, the term Wellness Exam has largely replaced the traditional physical and this has led to some confusion among patients and clinicians alike. It is important for patients to understand the goals of a Wellness Exam and how they differ from an appointment to treat a specific illness, injury, or chronic condition. Understanding these different visit types, and how health plans cover them, helps patients make the most of their coverage and avoid surprise treatment costs.
The difference between a physical and a wellness exam
The Affordable Care Act (ACA), which overhauled the nation’s healthcare system in 2010, emphasized prevention. Catching chronic conditions early, when they can be treated more effectively and affordably, improves outcomes. For example, the cost of a colonoscopy is much less than treating colorectal cancer. According to the Centers for Medicare & Medicaid Services, catching chronic conditions early and encouraging healthy habits lowers medical costs in the long run. In the years since the ACA’s passage, the term Wellness Visit or Wellness Exam has often replaced what was once known as a yearly physical.
Preventive vs. diagnostic appointment
Regardless of what it is called, many patients see their yearly exam as a no-cost opportunity to ask a medical professional about a variety of health concerns. And while clinicians welcome patient questions, they can impact the time allotted for preventive care and trigger additional costs. “If the issue is minor and doesn’t take much time, most clinicians will address it in a wellness exam,” said Dr. Kathleen Tonti-Horne, head of Kinwell’s Lifestyle Medicine program. “If someone mentions they have a bug bite, I’ll take a look at it and if it isn’t infected will prescribe some topical ointment. But if they have three or more concerns, each of which requires diagnoses and treatment, then we have to change the appointment from a wellness visit to a treatment visit and they can come back some other time for the wellness exam.” When a treatment is involved, an appointment changes from preventive to diagnostic and will then have a different copay associated.
What is and is not included in a wellness visit?
Patients can also communicate their priorities for a visit once they arrive at the clinic. Care coordinators or medical assistants will see if the intention of the visit has changed. Patients will also be asked to sign a new form that clarifies the scope of a Wellness Visit and reminds them that services beyond preventive care can result in charges, depending on their health care plan. It’s also possible that your clinician will note a concern during a preventive visit and advise that it be treated and addressed quickly. “This discussion is a bit of a dance between what is top of mind for the patient and what the clinician observes as part of their assessment,” said Dr. Mia Wise, chief medical officer for Kinwell. “The patient may be concerned about an odd mole on their back, while the clinician could determine that their blood pressure is too high and prioritize that treatment. Patients should expect a conversation with the clinic team who can help them identify the most important items on their list of concerns.”
How will you know if your visit is no longer considered preventive?
Kinwell clinicians are primarily concerned with patient well-being rather than costs, but they will try to let a patient know when a Wellness Visit (preventive) is veering into an office visit (diagnostic). Patients can help by asking if treatment for a specific concern will trigger an additional payment. In general, preventive care includes reviewing a patient’s health history about chronic conditions; preventing screenings like mammograms, colonoscopies, cancer screenings; and administering vaccines. During office visits, clinicians typically diagnose and treat short-term illnesses like headaches, rashes, back pain, and colds. Both preventive and diagnostic care can be delivered in the same appointment but may result in charges that are not 100% covered by health plans.
How to prepare for a primary care visit
If you’re sick or hurting, the agenda for your primary care visit is self-evident: diagnose the problem and receive the care you need. When dealing with yearly exams or chronic conditions, however, the agenda can be more free flowing. Assessing patient needs and expectations starts with a general understanding of what the patient hopes to address in each appointment. When making an appointment, patients can note their top concerns within the MyChart scheduling system or mention it to an associate if scheduling over the phone. Understanding a patient’s top concerns enables a clinician or their medical assistant to estimate the time required for assessment, diagnosis, and treatment. The clinician can also estimate the type and duration of an appointment and how it will be coded. This determines what is covered as preventive and what costs are the patient’s responsibility. Open communication ensures you are aware of the financial implications of your appointment.
Schedule your annual wellness visit at Kinwell Primary Care
To better understand what your plans covers as preventive care, call your health plan’s customer service team or view your plan online. You can schedule an appointment at a Kinwell Primary Care clinic near you online or by calling 833-411-5469. Established Kinwell patients can schedule through MyChart.
