Wiki Routine exams paid due to ACA now?

[Orthocoderpgu]

I work for a physician who performed a routine exam on a patient stating that due to the ACA the patient's insurance must cover the exam. However, the patient's insurance is not covering the exam. Does anyone know if ins now have to pay for routine exams due to the ACA?

 

[wannabecoder]

Some group plans can be considered grandfathered and they opt out of PPACA/ACA. Also depends on when the group renewed as well. (This is assuming the plan is a group/employer plan) Also if it was a routine exam done by a specialist vs a PCP that can make a difference as well. Have you contacted the carrier to find out the denial reason yet?

 

[lburke31]

in n.va there are still a lot of plans out there that don't cover preventive care. recently, we've seen some pts that purchase mini-medical plans that pay virtually nothing. you need to review card very carefully. we also have staff verify coverage ahead of time online or by phone. since a pediatric well w/ vaccines can be close to a $1000 charge, it's worth the extra effort spent. lburke cpedc
why is an ortho/specialist doing a well? that will only be paid to the pcp.

 

[dclark7]

What codes did he use? Not all codes are covered, they must have a grade of "A" or "B" according to the Preventative Medicine Task Force. There may be quantity or time limits placed on the code. Also, as lburke31 noted, an ortho would most likely not be charging a routine exam (codes 99381 through 99397).

 

[xstichr159]

Another thought - most insurances that do cover routine only cover one routine a year. If the patient is female and has seen her gyn, chances are her routine has already been billed.