Do You Need a Physical?

Did you know that most health insurance plans must cover an annual physical exam without cost to patients? This was one of Obamacare’s health care requirements to ensure that health plans are implementing quality and standardized care for all patients. And, believe it or not, a question I get asked a lot is: “Do I need a physical?”

The answer is it depends. It depends on how up to date you are on all of your preventative screening tests, your age, and how often you see your doctor. The short answer to this question is it’s always best to play it safe than be sorry later. If you’re not sure, then by all means, schedule that physical.

But what is a “physical” anyway? What does it entail? Will you be forced to have a pap smear or prostate exam? How can you best prepare for one?

What is a Physical?

The physical exam is really a lot more than an exam. It’s more than simply your doctor listening to your heart and lungs, asking you to say “ahhh” while opening your mouth wide, and examining your tummy.

Although the actual physical evaluation of the “physical” exam is one component, it’s much more than that. It’s a chance for your doctor to check inside your body based on the latest research and evidence informing the medical community (often the only way that services are covered), as well as to ensure you have met all of your preventative screening recommendations depending on your age. 

It’s about ascertaining if you’re up to date on these and more.

• Updating your vaccines
• Colon cancer screenings (colonoscopy)
• Pap smears for cervical cancer (did you know they are no longer recommended annually for many patients?)
• Breast cancer screening (mammograms)
• Osteoporosis screening (DEXA scans)
• Routine blood tests

Notice that I left out prostate screening. The guidelines for prostate health have changed in the last few years, and some groups do not recommend “routine” screening for prostate exams. But if you ask another expert group, they’ll tell you that men in certain age ranges should still be screened. Review this controversial medical topic with your doctor after having checked out my prior article on it, so that you’re armed with the most up to date knowledge and that the two of you can devise a personal plan together.

More than likely, your doctor will be examing you from head down. He may look at your eyes with the ophthalmoscope, then inside the ears and the back of the mouth with the otoscope. If all goes well, next is neck where the thyroid resides, and then listening to the heart and lungs which are two vital organs. He or she may ask you to lie back down to examine your stomach, and if the patient is female then sometimes a breast exam will be conducted. Next may be the skin and the lower extremities. 

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What is NOT Covered?

In our current health care system, it’s vital for patients to know what is and isn’t covered. Otherwise, you may find your insurance plan sending you an unwanted surprise bill. What I am about to tell you is something that even some doctors are unaware of.

Our complex health care system is not an easy one to decipher. As you may know already, there’s nothing cut and dry about it. No one knows what anything really costs. Especially doctors. Doctors who are employees (most doctors) of large groups or health care organizations are even more clueless.

Physical exams include preventative services only. 

Please note the focus on the word “preventative.” Your chronic medical problems may be reviewed, however most insurance plans do not cover the evaluation of “new” problems or acute concerns during this visit. That means if you have been experiencing dizziness lately and your doctor orders blood work that is non-routine for that issue specifically, then your plan may not cover it. Or, if you’ve been experiencing low back pain since the last time you saw your doctor two months ago and she orders an x-ray, it may not be covered, either. Or if you need a referral to see a surgeon for a new hernia this may also pose a coverage issue. Anything that is not preventative, whether it’s a blood test, x-ray, referral, or even the evaluation of an “issue,” may not be covered.

"That's infuriating," you might say. Yes. For doctors, too. It’s mysterious, bizarre, and elusive. No one knows what is covered and how much it costs. This is why something in our current health care model must change. None of us like it—not the doctors and certainly not the patients.

Truthfully, as a physician even, it took me some time to figure this one out. Your own doctor may be unaware. But now you are aware to take charge of your health.

If you are experiencing any new or acute problems you would like to discuss, it may be wise to schedule a separate visit for evaluation of that concern or ask to convert your visit from a physical to an office visit. Otherwise, your plan may bill you separately for any coding or charges incurred for anything that is not preventative during the visit.

If you have health concerns or issues, schedule a regular office visit. If you are simply hoping to ensure that your preventative health is maximized, then please schedule that physical exam.

Here's another thought—what if you contacted your health plan on your own? Ask them what is and isn't covered under your health plan during a physical. 

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Please note that all content here is strictly for informational purposes only.  This content does not substitute any medical advice, and does not replace any medical judgment or reasoning by your own personal health provider.  Please always seek a licensed physician in your area regarding all health related questions and issues.

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