Physical with no diagnosis (preventative), not covered
EDIT: Attaching EOB with PII blocked out.
In the online portal the services are described as:
- Office O/p New Low 30 Min
- Visual Acuity Screen
And they correspond to the two same services on the EOB
TL;DR: Does my doctor typically see a $528 cash payment due to denial for all their new patients? Makes no sense. I'll be calling them Monday, but I want to be prepared.
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I'm really good at fighting claims. I used to do this for a doctor, and I would often win claims to benefit both the patient and the doctor..all the time! I'm at a loss of where to begin for this one. I see paths in my mind, and I see them all getting shut down. Even though the unfairness of it seems so wrong.
My 14yo daughter is covered. Early May of 2025, she got her physical from her pediatrician. They also did a sports physical, as she was trying out in spring for a high school team. It was covered, $0 copay as it was her annual preventative visit. $328 billed, $0 copay. Services were: "Prev Visit Est Age 12-17; Collj Capillary Blood Spec; Hemoglobin; Brief Emotional/behav Assmt; Pt-focused Hlth Risk Assmt."
On the same insurance, mid-May of 2026, she needed a sports physical (the year of efficacy had passed), so she can do summer practices for her sport. In the meantime, the pediatrician died (the owner), and the practice closed / all other associates have gotten new jobs. I decided to bring her over to my own doctor and not establish her at a pediatric office anymore.
We set up an appointment, and they set is as new patient establishment; and I let them know she'll bring her blank physical form for the school system.
She had the appointment, and then they were like, let's set up her real physical for late June. I did feel they didn't do the full physical. It was more like a general conversation. No discussion of issues, just enough to fill out her form, get her vitals, weight.
Her May 2026 claim came back as denied.
Services were "Office O/p New Low 30 Min" and "Visual Acuity Screen" (which the visual screen she doesn't really need; she goes to an optometrist, and I guess this could be covered in her later real physical). Btw: the outcome of her visual screening was that she does not need glasses: 20/20 vision.
The denial was "Your plan's benefits don't cover this kind of care."
What? A preventative visit? No diagnostic codes. Why wouldn't it be covered? I will happily miss her actual, thorough physical, similar to May 2025, this week, if we can get the May 2026 "new patient visit" covered.
Amount: $528. All our responsibility. Because all I wanted was a physical for my child. *Note: I also didn't know they weren't going to do the through, actual physical. It makes sense if they want to see someone as a "new patient" first. But also, that shouldn't cost $528. And then adding the sports physical, I know some offices will charge $25-75 non-insurance-billed as a fee. What about this?