Some physicians still charge co-payments banned by law

• Different health insurance plans fall into different categories
• Co-payments for annual physicals prohibited under the law
• Advocates urge consumers to learn more about the law

WASHINGTON — Some doctors' offices are still charging patients co-payments for preventive exams, such as annual physicals and well-baby checkups, even though the Affordable Care Act prohibits the practice.

"Doctors' offices and staff aren't really educated about what is covered," said Monica Lindeen, Montana's insurance commissioner and state auditor and vice president of the National Association of Insurance Commissioners. "They don't know what they need to bill for and what they don't."

Because of the Affordable Care Act, most preventive health visits, such as mammograms, flu shots and colonoscopies, no longer require a co-payment or co-insurance if a person's coverage began after the law passed in 2010. Online chat rooms and medical sites are abuzz with complaints from people who learned too late that they needn't have paid an extra $25 for that blood pressure check.

"Everyone needs to educate themselves," Lindeen said. "If you have a plan that's grandfathered, or you got it before September 2010, then you may still have a co-pay."

Out-of-network visits may also require a co-pay, she said.

There has been some confusion about what constitutes a preventive visit and what requires a co-pay. For example, Lindeen said, if a mom takes a baby in for a well-baby visit, and the doctor treats the baby's rash, then the doctor's office can charge a co-payment for the treatment portion of the visit. If the doctor refers the patient to a specialist or schedules a follow-up visit, the initial preventive care visit should not require a co-payment.

Juliet Mavromatis, a doctor who runs a primary care practice in Atlanta and who writes for The Health Care Blog, said it's important that people understand this portion of the law because physicians have been pushing annual wellness exams for years.

"It's a positive," she said. "It gets people in the office, particularly people worried about money. It removes a barrier to people being able to check in at least once a year."

It means she gets a chance to check medical histories and family histories and to be able to record if there is a change in blood pressure or undiagnosed diabetes.

"The Affordable Care Act mandates that preventive care be available at no cost — even for high-deductible plans," Mavromatis said, "but there is confusion because we charge co-pays for every other visit."

Patients need to make sure they say it's a preventive care visit when they schedule an exam to help avoid confusion, she said. If the office accidentally charges a co-pay, it should refund it.

"The front-desk person may be unaware of the rule," Mavromatis said, "but if you use the appropriate billing code, my biller catches it."

If a customer believes he has been charged incorrectly, he should talk to his insurer, Lindeen said. Insurance documents, also because of the Affordable Care Act, should clearly lay out what preventive exams don't require co-pays, and it might help to take those documents to the doctor's appointment. If the problem continues, call the state insurance commissioner's office to complain, Lindeen suggests.

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