medical charges based on age chart
Chart, scanned from a Vermont legislative report on provider reimbursement for primary care services, shows an almost a 5% higher reimbursement rate to providers for CPT Code 99396 (well-woman ages 40-64) than CPT Code 99395 (well-woman 18-39). Click here for larger view.

While conducting our price surveys, we have learned that some facilities charge based not only on income, but also on age. In particular, at some facilities, an annual exam for a woman over 40 years old is often as much as $50 more than for an 18-39 year old.

When we asked why, we were told that there is more testing for women over 40. And yet, the patient does have a say as to what her exam should cover.

The American Congress of Obstetricians and Gynecologists lists its “Essential Elements of Annual Well-Woman Visit” on its Web site, and recommends a clinical breast exam (CBE) every one to three years for women ages 20–39, and an annual CBE and mammogram for women who are 40 and over. But paying


more, and going more often, can be cost prohibitive for the uninsured. ACOG also notes that “internal pelvic exams and/or breast exams should always be made with the patient’s consent.”

Beyond this explanation — could the pricing variation be an insurance thing? Most of the medical billing system in this country runs on the HCPCS (Healthcare Common Procedure Coding System) codes, a government system based partly on the CPT (Current Procedural Terminology)  numbers assigned  to a doctor’s or practitioner’s services, including exams, procedures, and surgery. Medicare, Medicaid, private insurance companies and others use these numbers to determine how to identify procedures and, based on that identification, what they will pay the medical practitioners.

For detail on how complicated the HCPCS medical coding system is, take  a look at the version of the chart below, detailing the differences: 10 minutes for one, 25 minutes for another; ages 18-39 for one, 40-64 for another.

One private practice in our pricing survey has two different price codes for a well-woman exam, based on age. This was also the only facility among the dozen or so that we called (this includes clinics, hospitals, and private practices), that has a separate price code for women over 40. Does this mean more money from the insurance company for the doctor for the same exam? Can a woman visiting this practice, who has no insurance, who is over 39, ask for her well-woman exam under price code 99395 (well-woman for 18-39), instead of price code 99396 (well-woman for 40 -64), and save $50?

We found some interesting information in a legislative report, the 2011 Provider Reimbursement Report Primary Care Services (2011 is the first and last of this type of report in Vermont, found here, according to a spokesman), in which the “Department of Banking, Insurance, Securities and Health Care Administration (BISHCA) conduct an annual survey of private health insurers doing business in Vermont to provide information comparing reimbursement paid to primary care providers. This information is intended to ‘improve our understanding of access to care, the cost shift, and workforce issues in Vermont.'” The survey included “the ten most common billing codes for primary care health services.” HCPCS codes starting at 99391 (under 1 year) through 99395 (including well-woman for 18-39 )and 99396 (inclluding well-woman for 40 -64) are in the top ten.

So arm yourself before heading to the doctor — always. Ask what it will cost, and also what it will cost you — under your insurance plan, your deductible, your employer’s plan, your family co-pay.

A related point: We understand that some clinics and private practices get discounts from different labs, such as LabCorp and Quest, which have different pricing scales. Patients have the right to choose what lab they want the doctor to use. Very few patients ask this question, and it may save them money.