Christine Rogers of Wake Forest, North Carolina, didn't hesitate when she was asked to fill out a routine mental health questionnaire during a checkup last November.

Her answers on the form led her primary care doctor to ask about depression and her mood, and Rogers said she answered honestly.

"It was a horrible year. I lost my mom," Rogers said she told her physician.

After what Rogers estimates was a five-minute conversation about depression, the visit wrapped up. She said her doctor did not recommend treatment nor refer her for counseling.

"It's not like anything I told her triggered, 'Oh my goodness, I'm going to prescribe you medication,'" she said.

Then the bill came.

The patient: Christine Rogers, 60, a public relations/communications worker who is insured by Cigna Healthcare through her job.

Medical services: An annual wellness visit, which included typical blood tests, as well as a depression screening and discussion with a physician.

Service provider: WakeMed Physician Practices, part of WakeMed Health & Hospitals, a Raleigh-based, tax-exempt system with three acute care hospitals, outpatient centers, and hundreds of physicians across a range of specialties.

Total bill: $487, which included a $331 wellness visit and a separate $156 charge for what was billed as a 20- to 29-minute consultation with her physician. Her insurer paid $419.93, leaving Rogers with a $67.07 charge related to the consultation.

What gives: Rogers said the bill came as a surprise because she knows annual wellness checks are typically covered without patient cost sharing as preventive care under the Affordable Care Act. And as part of an annual physical, patients routinely fill out a health questionnaire, which may cover mental health topics.

But there is a catch: Not all care that may be provided during a wellness visit counts as no-cost preventive care under federal guidelines. If a health issue arises during a checkup that prompts discussion or treatment — say, an unusual mole or heart palpitations — that consult can be billed separately, and the patient may owe a copayment or deductible charge for that part of the visit.

In Rogers' case, a brief chat with her doctor about mental health triggered an additional visit charge — and a bill she was expected to pay.

Rogers said she didn't broach the subject of depression during her checkup. She was asked when she checked in to fill out the questionnaire, she said — and then the doctor brought it up during her exam.

The Affordable Care Act requires insurers to cover a variety of preventive services without a patient paying out-of-pocket, with the idea that such care might prevent problems or find them early, when they are more treatable and less costly.

The federal government lists dozens of services of what is considered no-cost-sharing preventive care for adults and children, which includes such things as cancer screenings, certain vaccinations, and other services recommended by either of two federal agencies or the U.S. Preventive Services Task Force, an independent group of experts in disease prevention.

Depression screening is covered as preventive care for adults, including when they're pregnant or in the postpartum phase.

Rogers requested an itemized bill from her doctor's practice, which is part of WakeMed Physician Practices. It showed a charge for the wellness visit (free for her), as well as a separate charge for a 20- to 29-minute office visit. Earlier, Rogers said, she had discussed the initial bill with the office manager at her doctor's office, who told her the separate charge, roughly $67, was for discussing her questionnaire results with her doctor.

For Rogers, it wasn't so much about the $67 she owed for the visit, as it was a matter of principle. The separate charge, she said, was "disingenuous" because she was specifically asked about her mental health.

Also, annual physicals are intended to nip health problems in the bud, which sometimes requires a few more minutes of attention – whether it's to discuss symptoms of depression or palpate an abdomen for digestive issues

Some experts like Sabrina Corlette say the charge seemed a bit over-the-top: Depression screening "is now a recommended part of the annual physical," said Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University. "Implicit in that is someone looks at answers and makes an assessment, and you should not be charged for that."

Beyond the confusion of being charged for what she thought would be free preventive care, Rogers wondered how the bill was calculated: Her conversation with her doctor about depression did not last that long, she said.

A 20- to 29-minute-visit billing code is commonly used in primary care, reflecting not just the time spent, but also the complexity of the condition or diagnosis, said Yalda Jabbarpour, a family physician in Washington, D.C. She also directs the Robert Graham Center for Policy Studies, which researches primary care in the U.S.

Billing codes exist for other, shorter time frames, though those are rarely used except for the most minimal of services, such as a quick question about a test result, she said.

Physicians said Rogers did the right thing, emphasizing that patients should be honest with their doctors during preventive visits — and not keep silent about issues because they are concerned about potential cost sharing.

"If you have a condition like depression, not only does it affect mental health, but it can have significant impact on your medical health overall," said Stephen Gillaspy, senior director for health and health care financing at the American Psychological Association.

The resolution: Confused by getting billed for a visit she thought would have no charge, Rogers initially called her doctor's office and spoke with the office manager, who told her the claim submitted to her insurer was coded correctly for her visit. She then called her insurer to question whether a mistake had been made. She said her insurer said no, agreeing that the physician had billed properly.

Rogers paid the bill.

After being contacted by KFF Health News, and with Rogers' permission, the WakeMed health system investigated the bill and said it was handled correctly.

"We do split bills when a service is provided that is above and beyond the preventive components of a physical — in this case, beyond a positive screening for depression," WakeMed spokesperson Kristin Kelly said in an email.

By contrast, Cigna Healthcare, Rogers' insurer, sent her a new explanation of benefits statement after being contacted by KFF Health News. The EOB showed Cigna had zeroed out any cost to Rogers associated with the visit.

Cigna spokesperson Meaghan MacDonald, in a written statement, said the "wellness visit was initially billed incorrectly with two separate visit codes, and has now been resubmitted correctly so there is no cost-share for Ms. Rogers. We are working with the physician to ensure she is refunded appropriately."

The insurer's website says Cigna covers a variety of preventive services without copayment and encourages doctors to counsel patients about depression.

Not long after receiving the new EOB, Rogers said she received a refund of $67.07 from WakeMed.

The takeaway: While many preventive services are covered under the ACA, the nuances of when a patient pays can be complicated and open to interpretation. So, it is not uncommon for medical practices to narrowly interpret the term "preventive service."

That creates a billing minefield for patients. If you respond on a questionnaire that you sometimes experience heartburn or headaches, most physicians will inquire about your responses to assess the need for treatment. But should that come with an extra charge? Other patients have written to KFF Health News and NPR expressing frustration over being billed for conversations during a checkup.

Additional time spent during a wellness exam discussing or diagnosing a condition or prescribing medication can be considered beyond preventive care and result in separate charges. But if you receive a bill for a preventive service that you expected would be free, request an itemized bill with billing codes. If something seems off, ask the physician's office.

If you're billed for time spent on extra consultation, question it. You know how long the provider spent discussing your health issue better than a billing representative does. Next, reach out to your insurer to protest.

Most important, be honest with your primary care provider during your annual physical.

Emmarie Huetteman of KFF Health News edited the digital story, and Taunya English of KFF Health News edited the audio story. NPR's Will Stone edited the audio and digital story.

KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.

Copyright 2023 KFF Health News. To see more, visit KFF Health News.



It's time for our October Bill of the Month. Dr. Elisabeth Rosenthal is senior contributing editor with our partner, KFF Health News. Doctor, whose bill are we discussing today?

ELISABETH ROSENTHAL, BYLINE: This month, we're meeting Christine Rogers. She's from North Carolina. She lost her mother last year. Then at an annual wellness exam a short time later, Christine briefly spoke with her doctor about her grief. And that little conversation ended up costing her.

MARTÍNEZ: Costing her? I thought, usually, yearly checkups are free to patients, so that might have been a big surprise to Christine, huh?

ROSENTHAL: That's mostly true. Under the ACA, those yearly checkups are considered a preventive benefit and are supposed to have no patient co-pay. But some doctors and hospitals have a pretty narrow interpretation of what's included for free in those visits, and that can create a billing minefield for patients.

MARTÍNEZ: All right, let's hear the rest of Christine's story from reporter Stephanie O'Neill.

STEPHANIE O'NEILL, BYLINE: Christine Rogers and her mother lived a 13-hour drive from one another, Christine in North Carolina, her mom in a nursing facility in upstate New York. Between in-person visits, the two enjoyed chatting online.

CHRISTINE ROGERS: My mom loved animals. And so, you know, one of the things I would do when I would FaceTime her, I'd take my camera around. I'd go, oh, here are the cats, Mom. And I'd go outside, showing her, oh, the flowers are in bloom, Mom. Look, it's spring, you know?

O'NEILL: On an August evening in 2022, a nurse called Christine to say her mom, Patricia (ph), might not last through the night. The family jumped online. They found the 80-year-old in great spirits. So when a nurse called back that same night with news her mother had died, Christine was shaken.

ROGERS: You know, she was very cogent, very present in that moment. So that's why it was just, literally a couple of hours later, I was like, wait, my mom's gone? How can that be?

O'NEILL: Christine felt the loss deeply, and when it was time for her annual wellness exam a few months later, she noted that on a questionnaire handed to her at the doctor's office. During the exam, her doctor asked about it and Christine says she answered honestly that it had been a tough year.

ROGERS: I probably spoke to the doctor maybe five minutes based on my responses, and it was not like I was referred to another physician. I wasn't prescribed any medication.

O'NEILL: And she gave it no more thought until she discovered that the brief talk with the doctor generated a separate bill for a consultation, coded as having lasted 20 to 29 minutes.

ROGERS: I thought, oh, there was just some kind of mistake that might have been made. So I had called the office and they said, no, no, that's accurate.

O'NEILL: Christine knew that under the Affordable Care Act, annual wellness checks are generally covered with no out-of-pocket costs to the patient. She also knew people can be charged extra when they bring up a health issue that goes beyond preventive care. But Christine says she didn't do that. So in a call to the doctor's office, she pushed back.

ROGERS: And I go, well, wait a minute. It was part of my preventative care. This was a questionnaire that you asked me to fill out, and I'm being charged separately. I felt like I was upsold.

O'NEILL: Christine's share of the bill was just $67. It wasn't the amount of the bill that bothered her, rather it was that she got one at all, especially, she says, since it was the doctor who initiated that conversation about Christine's mental health and the grief over her mother's death.

ROGERS: To me, it was a matter of principle. And, you know, as patients, it should be abundantly clear during a physical what's covered and what's not.

O'NEILL: The doctor's office told us the bill was handled correctly. But after we contacted the health insurance company, the health insurer zeroed out the additional cost to Christine, and ultimately the doctor's office sent a refund. Christine Rogers got her $67 back, but she wonders how many other people are surprised by charges for care they think is part of their no-cost annual exam.

For NPR News, I'm Stephanie O'Neill.

MARTÍNEZ: All right. We're back now with Dr. Elisabeth Rosenthal.

Doctor, wow. We've had other patients write in to Bill of the Month just frustrated about getting an extra bill for having a conversation with their doctor during those preventative checkups. I mean, what gives here?

ROSENTHAL: Yeah, it seems a bit unfair. The additional time a doctor spends discussing a health condition or deciding on a diagnosis or prescribing you a medication can be considered by some providers to go beyond preventative care, but that's just not right. After all, the point of giving people free annual visits is to nip health issues in the bud before they become serious. So to patients out there, warning, if you check something on that health questionnaire you get in the waiting room and have a discussion about it with your physician, that could result in a legitimate - or at least legal separate billing charge.

MARTÍNEZ: Yeah. But I wonder - you know, it got me thinking, hearing Christine's story, that if, you know, a fear of getting an extra bill might cause people just to not talk honestly with their doctors, which, I mean, that would be terrible.

ROSENTHAL: Yeah, that is terrible. We know that, tragically, many Americans avoid health care for fear of the costs. But my advice is to be honest during your annual physical. Health providers need that input to give you the best care.

MARTÍNEZ: All right. Dr. Elisabeth Rosenthal, thanks a lot.

ROSENTHAL: Thank you.

MARTÍNEZ: And if you have a confusing or outrageous medical bill that you want us to review, please go to NPR's Shots blog and tell us all about it.

(SOUNDBITE OF BLACK TAFFY'S "GERALDINE") Transcript provided by NPR, Copyright NPR.

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