Common Questions on the difference between an Annual Exam and an Office Visit

Preventive care (or well services) and promotion of healthy lifestyles, is central to the Raby Institute’s philosophy of care. Most insurance plans, but not all, cover routine preventive exams at 100 percent when received from in-network providers. 

There can be confusion around what is included in an annual exam, how an annual exam is billed, and when to expect an additional charge for an annual exam. 

The following information was developed to aid in your understanding of the definitions and billing guidelines for annual exams and office visits. Ultimately, it is the responsibility of an insured individual to know their insurance coverage details. If you have questions, it is recommended that you call your health insurance provider to confirm coverage within your specific plan.

 

What is an annual exam?

An annual exam is a once-a-year visit to your primary care provider for a general health check and to identify potential health problems in the early stages when they may be easier and less costly to treat. An annual exam visit does not include discussion of new problems or detailed review of chronic conditions. Annual exams may also be referred to as yearly exams or preventive visits. 
 
Annual exam visits often include the following:
  • Update of past medical, social, work and family history
  • Complete physical exam and review of body systems
  • Review of medications, herbs and supplements (bring list)
  • Need for medication refills
  • Immunizations
  • Counseling/anticipatory guidance/risk factor reduction interventions
  • Review of age/gender appropriate screening tests
  • The exam is prevention focused, not problem focused. 

Annual Exams DO NOT include:
  • Discussion and/or treatment of chronic or acute issues
  • Discussion or treatment of new health concerns/issues.
  • Labs/diagnostic testing related to new issues.
 
An annual exam is part of your health care. If it has been more than 12 months, please contact your health care provider to schedule an exam. Ask any of our patient care coordinators to assist you in scheduling your annual visit with your Raby Institute Physician.


Could I receive a bill after my preventive exam even though it was supposed to be covered at 100%?

The Annual/Preventative exam is prevention focused, not problem focused. If you have a new health problem or other diagnoses that needs to be addressed during your preventive office visit, e.g. high blood pressure, diabetes, skin rash, fatigue, stress or headaches, your provider may bill part of the exam at 100 percent for your annual preventive exam and part of your visit as an office visit for treatment of your new diagnosis. 
 
The portion of your visit related to the treatment of your diagnosis would apply toward your deductible and coinsurance. If your provider feels that the majority of the time was spent with medical concerns, the entire visit may be considered a medical treatment visit and would not be billed as preventive. It’s important to note that your healthcare provider has the right to code and bill as they see the service from his or her viewpoint.


Will my provider address only what my health plan covers for a routine preventive exam?

Your provider does not know your health plan benefits and sees many patients with various insurance plans throughout the day. You are responsible for knowing what services are covered under your health plan. 
Review your Summary of Benefits prior to your preventive exam or call your insurance Customer Service for your benefit information.
 


What can I do to make sure I receive my routine preventive exam benefit (100% coverage in-network)?

You can take the following steps to help ensure your routine exam is billed correctly:
  1. When scheduling your routine preventive exam with your provider’s office, use the terms “routine preventive exam” or “annual physical."
  2. When you talk with your provider, let them know you are there for your routine preventive exam only.
  3. If you bring up health problems (i.e. skin rash, headache, fatigue, pain, high blood pressure, diabetes, etc.) during your routine preventive exam, understand that you may have an office visit charge related to the treatment of that problem.
  4. Do not save up all of your health concerns for your routine preventive exam. If you have a chronic condition or new health issues schedule a visit with your doctor. Schedule a separate appointment if you have health concerns – don’t wait for your routine physical exam to discuss with your doctor.
"The physicians and practitioners at the Raby Institute really work with me to educate me on how to take charge of my wellness. I am learning to be more aware of what my body, mind and spirit need to be healthy so I can live a full life."
- Raby Institute patient