Services at Aiken\u2019s appointment included a pelvic exam, a vaccination, and blood work, checking, in part, glucose levels and liver function.<\/p>\n
An annual physical exam typically includes a variety of services, many of which insurers are required to cover<\/a> under the Affordable Care Act, such as reviewing the patient\u2019s health history, screening for high cholesterol, or performing a Pap smear, a procedure to check the cervix for signs of cancer.<\/p>\n Updating immunizations is also a common, covered service at checkups. The vaccine for HPV, or the human papillomavirus, provides protection against an infection that can cause several types of cancer. Federal health officials recommend<\/a> being immunized for HPV at age 11 or 12, though the vaccine also can be administered later in life.<\/p>\n The Final Bill<\/strong><\/p>\n $1,430.13: $1,223.22 for lab services and pathology, plus $206.91 for \u201cprofessional services,\u201d which included a charge for a 40-minute \u201cHigh Mdm\u201d outpatient visit \u2014 indicating a high level of \u201cmedical decision-making\u201d \u2014 as well as charges for immunization administration and vaccines.<\/p>\n The Billing Problem: Diagnostic Blood Work With a Hospital Price Tag<\/strong><\/p>\n Not all services that may be provided as part of an annual physical are paid for by insurance as preventive care.<\/p>\n A patient who needs blood work for a specific medical concern \u2014 as Aiken did, for medication monitoring \u2014 could be required to pay part of the bill. That\u2019s the case even if the blood work is performed during a checkup alongside preventive services. Some health insurers pay for standard blood work as part of a preventive visit, but that\u2019s not always the case.<\/p>\n Aiken had purchased a health insurance plan on the federal marketplace and said they were confident the visit would be covered at no cost to them.<\/p>\n When they got a bill for more than $1,400, Aiken thought, \u201cHow did this happen?\u201d They said they called their insurer, BlueCross BlueShield of Illinois, then filed an appeal for the $1,223.22 amount they owed for lab services after their initial inquiry went nowhere. \u201cSurely this is a misunderstanding.\u201d<\/p>\n But their insurer sided with UI Health\u2019s position that the blood work rendered during the appointment was not preventive. In a letter denying Aiken\u2019s appeal, BlueCross BlueShield of Illinois decided that \u201cthe labs were billed correctly as diagnostic.\u201d<\/p>\n Under the plan\u2019s parameters, the insurer determined Aiken remained on the hook for 50% of the cost of outpatient labs performed in a hospital setting.<\/p>\n Dave Van de Walle, a spokesperson for BlueCross BlueShield of Illinois, would not discuss Aiken\u2019s bill with KFF Health News.<\/p>\n Francesca Sacco, a spokesperson for UI Health, said in an emailed statement that Aiken scheduled the appointment for \u201cmedication monitoring and to obtain a vaccine.\u201d<\/p>\n \u201cMedication monitoring is not considered a wellness benefit under the Affordable Care Act,\u201d she said.<\/p>\n Sacco also said Aiken\u2019s labs were sent for processing to University of Illinois Hospital, more than a mile away from the family medicine practice.<\/p>\n That left Aiken owing more. Hospitals typically charge much more<\/a> than physicians\u2019 offices or independent commercial labs for the same tests.<\/p>\n \t\t\t\t\t\t\t\t\t\t\t\t\t\t\tHe Had Short-Term Health Insurance. His Colonoscopy Bill: $7,000.\t\t\t\t\t\t\t\t\t\t\t\t\t<\/p>\n \t\t\t\t\t\t\t\tMar 28, 2025\t\t\t\t\t\t\t<\/p>\n \t\t\t\t<\/a>\n\t\t\t<\/li>\n \t\t\t\t\t\t\t\t\t\t\t\t\t\t\tA Runner Was Hit by a Car, Then by a Surprise Ambulance Bill\t\t\t\t\t\t\t\t\t\t\t\t\t<\/p>\n \t\t\t\t\t\t\t\tFeb 28, 2025\t\t\t\t\t\t\t<\/p>\n \t\t\t\t<\/a>\n\t\t\t<\/li>\n \t\t\t\t\t\t\t\t\t\t\t\t\t\t\tMost Insurance Covers IUDs. Hers Cost More Than $14,000.\t\t\t\t\t\t\t\t\t\t\t\t\t<\/p>\n \t\t\t\t\t\t\t\tJan 31, 2025\t\t\t\t\t\t\t<\/p>\n \t\t\t\t<\/a>\n\t\t\t<\/li>\n<\/ul>\n \t\t\t The distinction between a preventive visit and a diagnostic one is important for billing purposes: It dictates who\u2019s on the hook for the bill. A preventive visit generally comes at no cost to patients. But a visit for an ongoing medical issue is usually classified as diagnostic, leaving the patient subject to copays and deductibles \u2014 or even charged for two separate appointments<\/a>.<\/p>\n Patients may not notice a difference in the exam room. Much of that nuance is determined by the medical provider and captured on the bill.<\/p>\n Confusion still persists 15 years after the ACA\u2019s preventive services protections took effect, said Sabrina Corlette, a founder and co-director of the Center on Health Insurance Reforms at Georgetown University.<\/p>\n \u201cThis is an outrageous bill for what should have been routine care,\u201d Corlette said. \u201cPeople just don\u2019t have this kind of money lying around.\u201d<\/p>\n The Resolution<\/strong><\/p>\n After the insurer denied their appeal, they \u201cfell down a hole into despair about it for a while,\u201d Aiken said.<\/p>\n \u201cAnd then someone really wise was like, \u2018You can pay it and then just stop thinking about it.\u2019\u201d<\/p>\n So that\u2019s what Aiken did: \u201cI put it on my credit card.\u201d<\/p>\n UI Health\u2019s Sacco said the hospital system is committed to working with insurers to resolve cost-sharing disputes.<\/p>\n \u201cHowever, it is the insurance company\u2019s sole discretion whether a service is fully covered or subject to cost sharing,\u201d she said. \u201cIn this case, the insurer determined that cost sharing would be applicable to a specific portion of the services provided to the patient. Based on this determination, the patient was billed accordingly by UI Health.\u201d<\/p>\n The experience left its mark on Aiken. Last year, they said, they walked out of an urgent-care visit after a doctor recommended a Pap smear \u2014 fearing they\u2019d incur another large bill.<\/p>\n The Takeaway<\/strong><\/p>\n Delaying or avoiding care can lead to worse outcomes, which is why lawmakers tried to ensure patients generally would pay nothing for preventive services, such as immunizations, under the ACA.<\/p>\n Annual checkups are a key element of preventive care. For instance, most adults who never received the HPV vaccine do not know they are still eligible, so it\u2019s critical to inform them of their options, said Verda Hicks, a gynecologic oncologist based in Kansas City, Missouri.<\/p>\n The vaccine offers protection against nine types of HPV, she said. It also prevents HPV-related cancers in men, so the Centers for Disease Control and Prevention recommends boys receive the immunization, too.<\/p>\n \u201cGet vaccinated,\u201d Hicks said. \u201cWe just do not have the same tools for many other cancers.\u201d<\/p>\n Keep in mind that your coverage may vary \u2014 some insurance companies won\u2019t cover the cost of the vaccine for some older patients<\/a> \u2014 and the same services may be subject to different cost-sharing rules depending on whether they are conducted for prevention versus diagnosis.<\/p>\n Also, prices can vary depending on where care is delivered and tests are performed. If you need a blood test, ask that your doctor send the requisition to a commercial, in-network lab<\/a>. Patients may not realize that labs drawn at a clinic may be sent to a hospital for testing, exposing them to greater costs.<\/p>\n There has been a push in Congress to eliminate this price variation through \u201csite-neutral\u201d payment policies. Regardless of location, the price for routine care would be reimbursed at the same amount.<\/p>\n \u201cSite-neutral reforms could potentially have significantly reduced Carmen\u2019s expenses,\u201d said Christine Monahan, an assistant research professor at Georgetown\u2019s Center on Health Insurance Reforms.<\/p>\n Meanwhile, a case before the Supreme Court could upend the health system by eliminating the requirement that insurers cover preventive services like vaccines and annual screenings at no cost to patients. The high court heard oral arguments April 21<\/a>.<\/p>\n If the justices side with the plaintiffs this term, Georgetown\u2019s Corlette said, \u201cthen we all potentially lose access to free, high-value preventive care, and that would be a real shame.\u201d<\/p>\n Bill of the Month is a crowdsourced investigation by KFF Health News<\/a> and The Washington Post\u2019s Well+Being<\/a> that dissects and explains medical bills.\u00a0Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it<\/a>!<\/em><\/p>\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. 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