Your Insurance Pays for This Visit. Most Patients Never Use It.

The most common insurance confusion I see: a patient books their annual physical. That's a preventive visit, covered at 100% for most plans. Then during the exam, they mention they've had a nagging cough for three weeks. The moment I start evaluating that cough, we've crossed into a sick visit. Same appointment, two different billing codes, and sometimes a co-pay they weren't expecting.

I explain this probably fifteen times a week. It's not a billing trick. It's how insurance works, and knowing the difference can save you real money.

Here's the short version: preventive care is what we do when you're well. Sick visits are what we do when something's wrong.

Preventive care covers your annual wellness exam, recommended screenings (cholesterol, blood pressure, diabetes, certain cancers), immunizations, and health counseling. Under the Affordable Care Act, most plans cover these at no cost. No co-pay, no deductible. That's true for most HMO and PPO plans we see in Lake Nona and greater Orlando, whether you're on an employer plan, the marketplace, or Medicare.

A sick visit is different. You come in because you have symptoms: a sore throat, chest pain, that ankle you twisted at your kid's soccer game. Your insurance treats this as treatment, not prevention. You'll likely owe a co-pay, and depending on your deductible, potentially more.

Where patients get blindsided is when both happen in the same appointment. You come in for your annual physical, we're reviewing your labs, and you mention your blood pressure has been giving you headaches. That headache evaluation is a sick visit. Depending on your plan, I might ask you to come back for a separate appointment to keep your preventive coverage clean. It's about protecting the benefit you're entitled to, not creating more hassle.

My honest advice: when you call to schedule, be specific. 'Annual physical' means one thing. 'I've been dizzy for two weeks and also want my annual physical' means something different. This isn't gaming the system. It's using the benefits you're already paying for.

A few things specific to Central Florida. If you're on Medicaid or Florida KidCare, preventive visits are covered the same way, and cost should never be a reason to skip a wellness exam. If you're uninsured or have a high-deductible plan, ask us about self-pay rates before your visit. We'd rather talk through that upfront.

For our Spanish-speaking patients: if you got a bill you weren't expecting or have questions about your coverage, bring it in. We sort through insurance paperwork with patients regularly. You shouldn't have to figure it out alone.

Preventive screenings your insurance should already be covering: annual wellness exam (18 and up); blood pressure at every visit; diabetes screening if you're over 35 or have risk factors (with Central Florida's rates of Type 2 diabetes, this one matters more than most people realize); cholesterol panel every four to five years starting at 20; colorectal cancer screening starting at 45; mammograms starting at 40; and depression screening, which is covered as preventive care whether or not you feel like you need it.

For a deeper look at what these screenings involve and why they matter, our health resource partner VitaGuia (vitaguia.com) covers many of them in plain language, including in Spanish.

When to Come In: Don't Wait

Call us or come in same-day if you have chest pain or pressure, shortness of breath that's new or getting worse, a fever over 103 degrees, severe abdominal pain, a sudden headache that's different from anything you've had before, vision changes, or signs of infection in a wound. These are sick visits, but they're the ones where waiting hurts you most. We keep same-day appointments available specifically because this community can't always plan a week ahead.

The annual visit is the most underused benefit in most insurance plans. I see patients who haven't had a physical in five or six years because they felt fine. That's the visit where we catch blood pressure edging up, blood sugar drifting toward pre-diabetes, or cholesterol you'd want to know about earlier rather than later. Feeling fine isn't the same as being fine.

If you're not sure whether your visit would be preventive or a sick visit, call us first. Our front desk can help figure it out before you come in so there are no surprises.

We see patients at our Orlando location on Lancaster Road and at our Lake Nona office on Narcoossee Road. Dr. Catherine Arevalo and our team give unhurried appointments where questions are always welcome. If you've been putting off your annual visit because you weren't sure what it would cost, it's likely covered. We'd love to see you.

This article is for general informational purposes only and does not constitute medical advice. Please speak with your provider about your specific health needs and insurance coverage.