Routine Physical Not Covered...? Who's To Blame?

It is an unfortunate fact that millions of Americans rely on their medical care provider to know what their health plan covers. Thousands of times each day doctors are asked, "is this covered by my health plan?" Some doctors will answer "yes" or "no" and others refer the patient to their in-house insurance billing staff or the insurance company. But problems can and do arise when doctors answer in the affirmative. You see, to many patients a "yes" answer means that there are no out-of-pocket costs to them for the procedure. Meanwhile, the doctor is assuming that the patient understands that the care may be subject to a deductible or coinsurance. Therefore, patients end up paying a lot more for basic and non-basic medical services than they thought they would or should pay.

Whose Fault Is It Anyway

Patients. Even before passage of the Affordable Care Act, individuals started paying more for their health insurance plans and the healthcare they received through higher premiums, deductibles, and coinsurance. Politicians, policy makers, insurers, and employers claimed that it was important that the healthcare consumers had more skin in the game so that they understood the costs and value of their benefits. And those individuals would take responsibility for understanding how their health plan works and how to get the most value for their dollars.

The only problem or problems with this line of thinking is/are:

  • Most Americans hate navigating the healthcare system
  • Most Americans don't know how to navigate the healthcare system
  • The healthcare system is consciously but needlessly difficult to navigate
  • The healthcare system is not consumer-oriented
I could go on, but you get the picture--the latest healthcare it phrase, consumerism, is a lie. Healthcare consumers have too many obstacles to overcome to wisely use their health insurance. And the maddening reality is that insurers, politicians and policy makers acknowledge that the consumer is at a severe disadvantage in being able to compare the quality and costs of their healthcare coverage. What they won't acknowledge is that the whole deductible-coinsurance plan design is part of the problem. This complicated cost sharing mechanism, along with in- and out-of-network medical providers, are two primary reasons people don't understand their plan or just don't want to be bothered with it.

But that is not to say that healthcare consumers get a pass on understanding some of the basics of the healthcare system. In all cases, individuals should know that if you want to know what your insurance covers, contact the people you pay each month for the coverage. Healthcare consumers can also insists that their insurer and doctors work together to provide them with cost estimates for non-emergency medical care. They also need to acknowledge that it is ultimately on them to get the information they need before receiving any non-emergency care. Lastly, it is up to healthcare consumers to lobby for a simpler and more transparent healthcare system and not accept the status quo.

Doctors. No one is saying that doctors should understand health insurance as well as they understand their chosen profession. Nor should they have to know all the details of every patient's health plan. But there are some things we do expect them to know because like it or not many of them are part of the health insurance system. Unless they receive no compensation from private or public insurance, they need to respect the system that pays them and understand how it impacts not just their bottom line, but also their patients' bottom line.

For example, there is no good reason why every primary care physician in America should not be required to know what free
preventive services the Affordable Care Act covers. Physicians should be required to determine what services are covered as part of a routine physical and inform patients when they decide to provide services that are not covered as routine care. Additionally, doctors who develop a treatment plan or are the lead for a procedure should be required to tell patients when lab work or other routinely outsourced services like anesthesia may not be covered by their plan or are covered out of network. Finally, doctors (and hospitals) should be required to provide cost estimates for scheduled care.


There is no shortage of articles about how not to be surprised by medical bills, especially for what is supposed to be free preventive services. Healthcare consumers are warned that doctors may include tests that are not routine and, therefore, not covered as part of the physical. They may be told that if the doctor sent blood work to an independent lab, the lab may bill them separately. They may be advised to get treatment estimates before receiving care, and so on. But is this fair? Healthcare consumers have no or very little control over what care their doctors decide to provide and how much their insurance will or will not cover. We know health insurance companies have a huge responsibility in helping their clients understand and use their plans wisely. We also know that the consumer is ultimately responsible for paying their share of the costs for care, but hey, don't tell me doctors have no responsibility at all to look out for their patients' health and pocketbook.
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