Despite the benefits to patients, health plans' preventive care requirements outlined in the Patient Protection and Affordable Care Act pose a financial risk to medical offices, according to the American Academy of Family Physicians.
In a September 17 letter to HHS, AAFP board chair Ted D. Epperly, MD, FAAFP, described the following potential negative implications of its interim final rule for physicians:
"If a patient comes in for a preventive service visit, also called a 'well' visit, typically a co-pay will not be collected. If, however, during the visit, the patient brings up something else not related to a well visit and the physician bills the insurance company, many times, the insurer/payer covers the preventive service at 100 percent but the problem-oriented part at something less than the full cost. If the patient knows the preventive visit may be covered without any co-sharing, he or she may knowingly or unknowingly try to get the doctor to go beyond what is typically done at well visits to avoid paying a co-pay, which could put a strain on the physician-patient relationship. Most insurance companies will have edits to 'catch' this situation, but then consequently, they may turn around and pay the physician less than the negotiated fee schedule."
Thus, Epperly suggested the following rule revisions to HHS:
- Allow both a preventive service and a problem-oriented service to be billed when that occurs.
- Address the development of value-based insurance designs that "provide information and incentives for consumers that promote access to--and higher appropriate use of--value providers, treatments and services."
- Add language to the final rule that would clarify that the meaning of value is not solely a function of cost.