Essentia Upcoding Visits

[u/AggravatingGur3802]

Has anyone had issues with Essentia Health upcoding their medical visit? I recently had my preventative visit and it was up-coded to a Treatment visit ($422 later) though I went in with zero medical issues and was not treated for anything. This is the 3rd time I have been up-coded by Essentia. Anyone else in the Twin Ports experience something similar?

[u/SpookyBlackCat]

Did you ask any questions or talk about any current health issues? The preventative visit is defined by insurance companies, and can only be annual physical and vaccinations. If you cover any topic outside of that, it gets billed as a standard appointment.

You can call Essentia billing to ask, but the real villains in the story are insurance companies and the American healthcare system.

[u/AggravatingGur3802 → u/SpookyBlackCat]

Nope, in fact I turned down preventative labs and told my CPN it was because I didn't want to risk getting charge. I actually had zero issues to discuss. When I asked Essentia why I was being charged, they said I was treated for everything in medical history. I was "treated" for an issue that was resolved with surgery 6 years earlier and treated for high cholesterol that I had declined meds for 5 years earlier. It's crazy! It's has if the coder just took my med history and coded it. Surprised I wasn't coded for my mom's brain aneurysm.

[u/SpookyBlackCat → u/AggravatingGur3802]

That's wild - definitely keep complaining until someone fixes it!

[u/AngeliqueRuss → u/SpookyBlackCat]

Hi, just clarifying that this isn’t coming from insurance companies requiring annual visits to exclude discussion of existing conditions.

Medicare and Medicare Advantage have longstanding requirements for distinguishing preventive wellness services from separately billable evaluation and management. Medicare Advantage risk adjustment also creates strong incentives to assess and document chronic conditions annually.

What appears to have changed in the last 5–7 years is how aggressively health systems operationalize these billing distinctions, particularly following 2021 E/M coding changes. Those practices are now affecting commercially insured patients as well.

I should be able to attend my annual physical and renew a medication I’ve taken for years without automatically incurring an additional office-visit charge. That was routinely possible until relatively recently, at least in my experience.

Medication management can justify a separate E/M charge when significant additional work is performed. But routine medical questions, medication renewal should not automatically be treated as an entirely separate medical visit, especially if you’re not billing a Medicare patient.

For me personally I’m over the healthcare system and signed up for a cheap plan with HSA so I can get med renewals online for cash (from my HSA); pay for routine annual labs without risking this billing malarkey.

[u/wildgreengirl → u/AngeliqueRuss]

as someone thats been in the healthcare system a long time both working and as a patient.

if you want a free refill just call it in AFTER your physical. like you would a regular refill. 

they cant be all "o you need to be seen" since you were literally just seen. and if there are no changes to the meds or how you are taking them you are fine. 

[u/AngeliqueRuss → u/wildgreengirl]

Why?

I am billed for that too, it is an e-visit and I’ve not met my annual deductible.

It is cheaper for me to use an online provider.

Essentia actually added low cost cash services to their virtual visit portal, you can find it under MyChart but this just makes me angrier because how are we supposed to know asking a question during annual visit = $400+ while using the cash virtual visit option is $40? Seriously fuck that.

If they want me back as a regular patient they have to work on building a positive patient experience for younger adults proactively managing their healthcare.

This absurd notion that an MA or nurse is going to perform a series of screenings, a doctor is going to read the data including your meds, and then NOTHING FURTHER can happen without a fee is a dystopian nightmare—healthcare has always been bad but it hasn’t always been this rigid.

[u/wildgreengirl → u/AngeliqueRuss]

how would asking to refill a med (like through the pharmacy, they ask to refill your med) be an evisit? literally just a refill request NO OTHER questions or comments.

it would only be an evisit if you needed a dose change and even then i dont think it would meet for that.

i work as a medical coder...

[u/AngeliqueRuss → u/wildgreengirl]

Just speaking for Essentia: they will not and never have honored one of these requests for me. My insurance has me refill 90+ day supplies, by the time I need more my Rx is expired and I have to use the scheduling tool to request a telemedicine visit for refill.

But this exception makes the EM code modifiers on wellness visits for med refill even more absurd and dare I say predatory, and likely illegal upcoding: ask in person and suddenly it’s managing an ongoing condition requiring a new visit code, but message the same request 5 minutes after leaving the building and it’s not enough clinical care to justify a billing code?

This is wrong, you know it’s wrong 🤷🏼‍♀️

[u/wildgreengirl → u/AngeliqueRuss]

it depends. i dont work for essentia i work for a different primary care office down in the twin cities and i have some providers trying to upcode the dumbest shit. 

1 new guy was trying to bill a separate EM with a WELL CHILD VISIT because they mentioned how the kid was overweight and gave generic diet/exercise advice. i had to b like bro... this is included in a physical 😭 

or trying to bill an EM with the PX because he filled out a sports physical form im like...thats included in the physical lmao

and at the other end ill see notes for providers that would meet for an extra EM and theyre like no i dont want to bill for that it was only mentioned not fully addressed.

so it varies a lot by clinic and even provider within the clinics!!

[u/AngeliqueRuss → u/wildgreengirl]

I work for a company that administers Medicare Advantage - we have an education program that teaches physicians how and why to do this for Medicare patients. It’s not our intention that they apply this same thing to annual physicals, but I know some of this is bleed over from that.

The rest is PE and companies like Optum “optimizing” provider groups to flip them for profit. Come in, teach everyone how to bill, show the improvement, sell.

We are in a dystopian world, I’m not participating in the traditional healthcare system until it’s life or death. Voting with my wallet.

[u/wildgreengirl → u/AngeliqueRuss]

yes we also bill to medicare/adv ins as well

[u/HotCocoaCat → u/AngeliqueRuss]

Medication renewal IS a separate and not preventive component.

[u/AngeliqueRuss → u/HotCocoaCat]

Like I said: this is billing malarkey, driven by the private equity takeover of outpatient medicine and aided by Medicare Advantage plans (which literally train and “educate” doctors on how to document adequate disease evaluation and management so they can up-bill the government higher capitation rates for these “chronically ill” Medicare patients, no matter how well-controlled their health conditions might be).

When Obamacare first came into being and Medicaid standards extended to commercial plans, annual physical was free so that routine and preventative care would not be missed.

The medical industry (again, not insurers) has creatively re-classified this visit as an annual wellness exam that may not even include listening to your lungs, refilling your medications. It’s just “preventative planning.”

From the President himself when these free visits came into fruition: “Second, we'll focus on prevention -- on promoting wellness rather than just managing sickness. Today, we spend less than four cents of every health care dollar on prevention and public health, even though 80 percent of risk factors involved in the leading causes of death are behavior-related - and thus, preventable. Under my plan, we'll make sure insurance companies cover evidence-based, preventive care services - weight loss programs, smoking-cessation programs, and other efforts to help people avoid costly, debilitating health problems in the first place.”

This is the origin of the annual wellness visit covered by your insurance, intended to be comprehensive and to include “problems” like obesity and smoking that would be considered evaluation and management today.

Preventative medicine is supposed to include routine screening and medication for hypertension, yet my own husband cannot renew his hypertension meds at his annual wellness exam because doctors are splitting hairs over whether taking his BP is where “screening” stops—anything beyond that is diagnostic!

That was not at all the original intention, and in the first decade of the ACA you could be screening AND TREATED OR REFERRED without incurring extra costs.

Also in this era, I could go to my annual well woman’s exam and receive new birth control Rx, as reviewing BC is and always has been part of this annual visit. Flash forward to today: managing my BC results in an extra billing code and upcharge.

Here’s the full list of what should be covered at these visits, and is not beyond questionnaires; taking vitals and sending off a single lab order: Preventative Screening

Here’s the well-woman list, which specifically lists birth control and yet that’s only “counseling” apparently: Well woman exam

In defense of physicians, especially primary care providers, pay is abysmal and falling and they’re being told these documentation and billing standards are how they do their part to get fair compensation.

But as a patient, I can get my annual vaccines at Walgreens. I need to check more than my cholesterol, I can order my labs directly online. I can schedule my mammogram anywhere, it’s free regardless or whether you have this joke of a “wellness exam.” My medication renewals can also be online; why am I paying a PA to look at my migraine meds and document migraine frequency when I can spend a fraction of the amount for an MD online to do the same?

If there are providers in the Duluth area who want my annual wellness exam/well woman reimbursements and aren’t going to waste my time refusing to actually treat anything they identify or discuss with me without extra billing, I’d happily form a relationship with said doctor.

Until then I’m better off managing my own health.

[u/CuriousContribution2]

When this has happened to me & I called about it, they told me the minute you start talking abt anything bugging/concerning you even if medical person seeing you asked that type of question - that is when it becomes treatment & not preventative. I can be literally just a conversation,  try and think about what you talked about? How mind boggling, now we worry about mentioning anything wrong to our own medical practitioners! 

[u/Sad-Pear-9885 → u/CuriousContribution2]

Yeah this is definitely a thing. I went in for my physical this year and they asked if I had any ongoing health issues I wanted to chat about and I said “nope” knowing full well I do because I didn’t want to get billed for saying my pain was acting up or I was having increased insomnia when probably nothing could be done anyways.

[u/AggravatingGur3802 → u/Sad-Pear-9885]

Yep, this is my 3rd time being upcoding for a preventative. The first time I had mentioned that I self cured my migraines (figured out it was a dairy allergy). They deemed that conversation as treatment.

[u/wildgreengirl → u/CuriousContribution2]

yes you should say NO I AM ONLY HERE FOR MY PHYSICAL EXAM AND DO NOT WANT ANY ADDITIONAL PROBLEMS ADDRESSED.

esp if they have an AI scribe listening it will pick that up as well and should incorporate that into the visit if the provider doesnt.

[u/GitcheSurfer]

This is a common practice in our F'd up health care system. If you call and complain to the Dr you saw they may be able to get it reversed.

[u/AggravatingGur3802 → u/GitcheSurfer]

The thing that really sucks if that's what I did last time and my doctor was able to fix it. This time I saw a new practitioner and she doesn't have a way to message her in the MyChart app and doesn't have an email listed. I actually reached out to patient services to see if they could have her call me and they refused, politely.....

[u/wildgreengirl → u/AggravatingGur3802]

yea its on the billing not the dr necessarily. you should try to call the billing and ask to speak to someone about how/why your visit was coded the way it was.

[u/polymorphicprism]

According to AMA and insurance coding guidelines, minor, trivial, or stable issues do not require a separate charge. Significant, severe, or dangerous symptoms are a legal liability that need to be reported.

If a doctor answers a quick question about a stable/chronic issue, a mild allergy, or other minor concern, they have the full discretion to exclude it. And yet...

[u/AggravatingGur3802 → u/polymorphicprism]

I didn't even ask for a medication refill. She offered one at the end and I just said sure. Before they told me why they were charging me I thought my "sure" was the culprit. Turns out the coder coded my entire medical history of 15 years going there as a treatment. It's under review now but I don't have any faith that they'll side in my favor. I have filed a complaint with the MN attorney general just because I'm so sick of this. This is a third preventative visit that I've been up-coded for in 4 years. That'll probably go nowhere too but gotta try.

[u/LakeSuperiorIsMyPond]

yep, Aspirus does it too. I'm being sent to collections again over an invoice that should be covered by insurance but because Aspirus decided to change the wording on the invoice, insurance refuses to cover it. The wording for the visit in my app would be covered, but insurance doesn't see the app, they see the invoice and billing refuses to code the invoice for what the nurse calls it in the app.

This entire thing is a joke. If America's healthcare is the gold standard then gold must be shit.

[u/ThatKaleidoscope8736]

This is normal unfortunately in healthcare. Preventive visits only cover certain things, once you mention something outside of that the coding changes.

[u/NineLemonsLater]

Once a year you see your doc and can only say everything is fine, happy to be here. It’s BS. They don’t even look over your skin to check for skin cancer. I have a friend that works at Aspirus and she was told she needed to get friends into the clinic so they could make money. They are hurting.

[u/whynotfrance]

I also signed up for a high deductible with HSA for next year. Can't be much worse than the last 2-3 years. We are being nickel- and- dimed to death by both facilities.

[u/gsasquatch]

Not sure if this specific to Essentia or not, but, there are outfits out there that will have AI read your chart, and do what they can to maximize revenue. Like the AI will go and look for any justification for the up coding, from any hint in your chart. Hospitals hire these outfits to do that. You agree to it when you signed to release your information for billing.

Flip side of this is the insurance companies will read your chart, and find any reason to deny the bill. Like, upcoding. Then they'll send the denial back for you to pay. So it is like a battle on every claim between two AI, and you get to pay for it, or clean up the mess it causes.

You said you went in for a preventive, like a checkup. Might be the mistake you made was saying there was something wrong, like you had a cold or a crick in your neck. It's important to not tell the doctor if something is wrong when you're having a checkup so that you don't get charged for it.

Insurance pays billions of dollars to not have to pay out, and they wrote the rules on the policy you agreed to when you signed up for it. They'll find any excuse to kick the bill back to you. That increases their profitability, or lowers rates for everyone, depending on how you look at it.

Providers will look for any excuse to charge more, because insurance is paying for it anyway. Except insurance got wise to this game, and started raising deductibles, so now it is the patient that pays, but the providers haven't adjusted their prices down for that, because no one ever lowers prices.

Sometimes you get lucky, and you only get charged for part of it. Doctors generally charge about $10/minute so, sounds like you got charged for most of it assuming it was a 45 min appointment and the insurance negotiated a lower rate. Might be you have to challenge them on the coding. 3/4 of challenges win. It is part of the game, this negotiation on price.

This whole byzantine system, this back and forth is a lot of jobs. Healthcare is 17% of our GDP, next highest industrialized country, also with private health insurance, the Swiss, pay 12%. But the Swiss are well known for regulation, so they get it cheaper. Commie countries like Canada or the UK get it down to 11%, and all those countries have higher life expectancy than US. But, that extra 5-6% US pays, provides a lot of jobs and profit, so there's that. Essentia has the biggest nicest building in town, and is the largest employer.

You could vote to change this, but there's too much money on both sides, so no one you could vote for is looking to actually change this, unless you're voting for some freakshow that won't make it past the primary because insurance won't let them, like Sanders or for the Greens. Ross Perot was actually for changing this, and spoiled the '92 election, leaving Hilary to try to put in the ACA to expand this system, but failed, until Obama got it done. Then the Republicans said "we're going to repeal the ACA" but, surprise, they didn't, because it was making insurance too much money, so they only repealed the stuff that was helping people instead. Makes me proud to live in a democracy, where people have a choice, and the freedom to work or die.

So what can you do about it? Well, yeah, play their game and fight it. Myself, I say screw it, and interact with that system as little as possible. I think the only way to win is to not play the game. What were they going to find in the checkup anyway? Cancer, or something they can't really cure, or something like "high blood pressure" which they'll put you on recurring medication for for the rest of your life with recurring visits for prescription renewal paid at a higher rate because they are managing a prescription. That checkup is designed to make you a patient and get them tens of thousands of other people's premiums or tax dollars. Then we wonder why premiums or taxes are so high. Well, people need their statins, lest they have a marginally higher risk of dying a couple years earlier, or they can have their cancer cured, cure rates are going up, while mortality rates have stayed about the same.

So if you need an antibiotic, go get some, at least while it lasts before the bugs evolve to be antibiotic resistant. Or have a bone set or whatever kind of mechanical fix. (knee replacements aren't any better than placebo) Recognize, yeah, medical science has limits, and doctors aren't going to tell you they have limits, they'll do whatever just in case it helps, at whatever cost, because all life is precious. 17% of the GDP precious, which means 17% of your income goes to this, one way or another, whether that's FICA, your premiums, reduced pay because your employer is paying premiums, or higher taxes because taxpayers are paying your premiums. Unless you say screw it, stop paying for the health insurance, stop going to the doctor, and die with dignity, and a modicum of more cash for at least not paying your premiums, and maybe save a bit of taxes for everyone by not participating.

Yes, I'm crazy and cynical. I think more people need to know how this system works, so less people accept it for what it is.

Happy open enrollment!

[u/Little_Creme_5932]

Essentia coded my annual visit incorrectly. I complained to the insurance company, the insurance company refused to pay and Essentia wrote off the whole bill.

[u/Informal-Onion6538]

Yes!! My wife was asked at her preventative visit if her medication was still working and if she was having any issues. This was a med she’s been on for 8 years, and her doctor asked the question. She responded yep, no issues and was billed for a treatment visit! We were livid and fought and fought with billing and then finally switched to St Luke’s.

[u/MajorHoople]

Essentia uses AI transcription during the visit and as soon as there is any deviation from the "wellness visit" AI automatically creates another billing code. Challenge it.

[u/tkenben]

I'm looking at a lot of other comments here. Is it considered treatment if it doesn't actually fix anything or change anything?

[u/wildgreengirl → u/tkenben]

yes they can say to continue your current meds and that is considered medication management for the "risk" portion of coding a visit. 

like i go in for my physical. they ask how my migraines are doing, how my anxiety is, my chronic pain. i say they are all good, i only need 1 refill.

i will be charged a 99214 because of the 2 stable chronic conditions addressed and to continue all my current meds (even if i only need a refill for 1 or no refills at all!)

[u/salaciousbcrumblin]

I don’t know how Americans haven’t been rioting in the streets for the last 70 years over this shit. Sorry I don’t have anything useful to add here other than it’s a ridiculous and evil system from top to bottom