Preventive care is covered at 100% with no deductible and no copay on every ACA-compliant plan. So when the EOB for your annual physical shows an amount you owe, your first thought is that the insurer made a mistake. Usually it did not. Here is what almost always happened.
The short version: your visit was billed as two services, not one. The preventive part was covered in full. The other part was not.
Sample EOB — annual physical with a problem addressed
| Provider | Cedar Ridge Family Medicine |
| Date of service | March 4, 2026 |
| Line 1 | Preventive visit, established patient (CPT 99395) |
| Billed / Allowed | $260 / $185 |
| Plan paid | $185 ← Covered at 100%, no deductible |
| You owe | $0 |
| Line 2 | Office visit, problem-focused (CPT 99213, modifier 25) |
| Billed / Allowed | $180 / $124 |
| Applied to deductible | $124 ← Deductible not yet met |
| Plan paid | $0 |
| You owe | $124 ← This is the charge you are asking about |
What the Second Line Means
You went in for a physical. While you were there, you mentioned your knee had been hurting, or your heartburn was worse, or you wanted your blood pressure medication adjusted. The doctor addressed it.
That conversation is not preventive care. It is a problem-focused visit, and it gets billed separately using a second code with modifier 25 attached — the modifier that tells the insurer “a distinct, separately identifiable service happened on the same day.” Your plan covers the physical at 100%. It applies your normal deductible and cost-sharing to the rest.
Is That Allowed?
Yes, and it is not a loophole. If a physician evaluates and treats an active problem, that work is real and billable. The rules permit both codes on the same day when the problem-focused work is genuinely separate from the preventive exam.
What is not permitted is billing a problem visit for work that was part of the preventive exam itself. Reviewing your history, ordering routine screening labs, checking your blood pressure as part of the physical — that is the preventive service, and it should not generate a second charge.
When to Push Back
Look at the second line and ask yourself honestly whether a separate problem was addressed. Two situations are worth disputing:
- Nothing new was discussed. If the visit was only the physical and routine screening, the second code may have been added in error.
- You raised something in passing and it was not evaluated. Mentioning that you sleep badly is not the same as being assessed and treated for insomnia.
To dispute it, request an itemized bill and the visit notes from the provider, then call the billing office first — a miscode is fixed faster by the practice than by the insurer. If they will not amend it, file an appeal with your carrier.
How to Avoid It Next Time
You cannot always avoid it, and you should not avoid raising a real health concern to dodge a charge. But you can control the surprise: at the start of the visit, say plainly that you are there for your annual preventive exam, and ask whether anything else you bring up will be billed separately. A good practice will tell you, and you can decide whether to handle it that day or book a follow-up.
Check the Preventive Line First
Before you dispute anything, confirm the preventive line itself processed correctly. On the sample above it shows the plan paying the full allowed amount with nothing applied to the deductible — that is what a correctly processed preventive service looks like. If your deductible was applied to the preventive line, that is a genuine processing error and worth a call to your insurer.
If you are stuck on a charge you think is wrong, call (713) 575-9904 and I will read the EOB with you.