Get More Out of Your Primary Care Doctor’s Visit

This is probably one of my most requested topics because so many of my clients get very frustrated in how much time and money they spend on Primary Care Doctor appointments that result in little to no progress.

It’s also frustrating to the doctors with whom I’ve spoken.

Getting more out of your Primary Care Doctor’s appointment should be easy right? You need their expertise and they went into medicine to make people feel better. 

Then why is it so hard to get care that helps?

Because there’s an elephant in your exam room – your insurance company.

The number one mistake that I see people make is not being aware of and accepting that MEDICINE IS A BUSINESS.

U.S. health care spending grew 9.7% in 2020, reaching $4.1 trillion or $12,530 per person.  As a share of the nation’s Gross Domestic Product, health spending accounted for 19.7 percent.

Centers for Medicare and Medicaid Services, National Health Expenditure Data, Historical

When you go to the doctor, you are essentially going to a business meeting between you and two other parties: your Doctor and your Insurance Company. In this business meeting, you are paying the doctor for their time, wisdom and expertise and are therefore ultimately fully responsible for the cost of the appointment. You have contracted with the health insurance company to help make the visit more affordable.

Your expectation should be that the meeting will have direct value to you. Your goal then is to work with the doctor to figure out what care is needed and the priority levels of the proposed care in case the whole treatment plan is too costly to implement.

Here are the roles in the exam room:

• You: come in with concerns and are consulting with the Doctor on how to best address them.
• Doctor: provides their recommendations and proposed treatment plan. They have absolutely no idea how much their plan will cost you and whether it will be covered by your insurance plan.
• Insurance: determines what they will pay for and what will be your responsibility AFTER THE FACT with insurance. As of 2022, if you are self-pay or uninsured you should receive a Good Faith Estimate PRIOR to receiving non-emergency services.

Because everything really comes down to insurance, before you even make a healthcare appointment, it’s wise to get very familiar with your insurance policy. 

If you do not have insurance or are not using it because the Self-Pay prices are cheaper, you will want to ask for that Good Faith Estimate when you schedule your appointment.

SIDE NOTE: For the purposes of this post, I am going to use the word Doctor to describe a licensed medical professional. Not all medical professionals are Doctors (Physician Assistants and Nurse Practitioners) and so the better term probably would be Healthcare Provider (HCP) or Healthcare Professional but those terms are not as widely recognized yet.

Insurance

In 2020, 91.4% of Americans had some form of health insurance.

However, 28 million Americans still went without insurance. Since there are times that even those with insurance (especially high deductible plans) may be better off paying a cash price, I’ll briefly discuss how to negotiate cash prices too.

Step 1 – Get Your Policy Document

If you have health insurance, the number one thing you need to do is ASK FOR YOUR HEALTH INSURANCE POLICY DOCUMENT. Usually your Human Resources Department should be able to provide this to you or you might be able to find it online in your insurance portal.

This is NOT the Summary Plan Document – you want the POLICY document. It’s usually over 50 pages long and it includes all of the fine print of your healthcare policy, specifically:

• How much the insurance company will pay for and what your responsibility will be for In-Network vs. Out-of-Network Coverage
• What types are services are included
• What types of services are excluded
• What needs prior authorizations

This document is very important because it spells out exactly what benefits and coverage you have.

Pay close attention to whether you have any out-of-network coverage.

If you do, this document DOES NOT HAVE the “allowable amounts” that the insurance company sets for certain charges. These allowable amounts become very important if you are seeking out-of-network care.

Insurance companies have started to set their allowable amounts very low and then paying their contracted percentage off a low value. You are then required to pay the remaining balance.

For instance, say your out-of-network appointment cost $250 and you paid it in full and submitted it to the insurance company. They are contractually obligated to pay 70% of the claim (assume deductible has been met) but their “allowable amount” for the appointment is only $120. That means they pay 70% of $120 or $84 and you pay $166.

Step 2 – Review Policy Document for Specifics

In preparation for your doctor’s visit, you’ll want to review that Health Insurance Policy Document specifically for coverage (deductible, co-pays, co-insurance) related to:

• Office visits
• Lab testing
• Imaging services
• Whether you need a referral for specialist appointments or to seek out-of-network care

NOTE: Annual wellness visits are covered at 100%, HOWEVER, these visits are very limited in scope which means you very likely will receive a bill for an office visit. Lab testing and imaging services recommended as follow-up to these appointments also are not likely covered unless they are related to routine preventative care (mammograms/colonoscopy, etc.)

For Cash Pay, here are some resources:

• Ask the doctor’s office for a Good Faith Estimate for a Cash Price
• Doctor Visit Costs (Summary of Basic Costs)
• Medicare.Gov – One of the largest insurers in the U.S. and often sets the standard for reimbursement rates so it can give you a basic idea of costs. You will need the CPT code or procedure code from your Provider (what code will they bill).
• Hospital Pricing Transparency (get a rough idea on costs)
• Your insurance company online portal should give you an idea of costs

After you have an idea of what your insurance will cover or how much a Cash Price will be to see a doctor, the next step is to find one!

Skip this next step and proceed to “Prepare for Your Appointment” if you already have a doctor that you love.

Find a Primary Care Provider (PCP)

Before we get into these steps, let’s first discuss the seven types of Primary Care Providers:

• Walk-in Retail Clinics
• Direct Primary Care & Concierge
• Internal Medicine Doctor
• Family Medicine Doctor
• Nurse Practitioner
• OBGYNs (Well Woman w/cervical screening)
• Government Health Clinics

A Word About Walk-In Retail Clinics

These types of clinics are usually in retail places such as CVS or Target and are not urgent cares meaning they may cost the same as a Primary Care visit. They also usually are very transparent about their cash prices. They are often staffed by Nurse Practitioners and can be a great way to access care quickly.

While the purpose of these clinics’ is to provide care for illness and minor injury, they can perform many Primary Care related tasks such as: conducting physicals for school, employment or general health, order lab testing and imaging studies, prescribe medication, provide basic follow-up care and help monitor chronic conditions.

In my opinion, they are not a replacement for a Primary Care Doctor relationship.

Why?

Because retail clinics main purpose is to offer immediate care for illness and injury. Their main focus is not on preventative medicine and the turnover in these clinics is often high meaning you’ll likely be switching providers frequently which can negatively impact your care.

Primary Care Doctors also serve as a type of “hub” for your medical journey. Once you establish care with a Primary Care Doctor, you can list their name any time you receive care from anyone else and your medical records from that appointment will automatically be sent to your Primary Care Doctor. This allows for much easier and more seamless care coordination.

I feel strongly that building a relationship with a Primary Care Doctor who knows your medical history, sees you at least annually and can track your health over the long-term is the best way to Secure Your Health for a lifetime.

Direct Primary Care & Concierge Medicine

Another alternative model to the traditional doctor/patient relationship is where you hire your doctor directly via a Direct Primary Care or a Concierge Medicine Model.

In the Direct Primary Care (DPCs) model, you pay a monthly membership fee (usually a few hundred dollars per month) to your doctor and that gets you a certain amount of covered services (most of which are 100% included as part of the fee). These services can include a fixed number of office visits, lab testing, care coordination and management. DPCs also often have open contact policies meaning you get your Doctor’s personal phone number to call or text.

It sort of is like the old days when your family doctor was almost like another family member – it is direct access to your Doctor. In some cases, DPC Doctors actually do make house calls and that’s their main method of seeing patients. This can work extremely well for people who have special needs, people confined to their home, or those with mobility issues.

In the DPC arrangement, you do not use insurance; you just pay the monthly membership fee to the provider and receive a certain amount of covered services. Bear in mind, you will still need insurance to cover all of your other health expenses.

In a Concierge Medicine Model, the arrangement is similar to a DPC but also very different. Concierge practices usually charge an upfront annual fee ($1,000s+ per year that can be paid monthly, but the obligation is often an annual amount) and then charge per service. Since these practices charge per service, they can often submit to your insurance as an out-of-network provider, though some may take insurance or Government benefits. The idea here is that the Concierge fee allows the provider to have more flexibility in how they craft their practice as insurance reimbursement is not their sole source of income.

Both care delivery models are relatively new with Concierge Medicine being slightly older. The healthcare industry is keeping a watchful eye on how these new practice models develop and how they impact patient care.

Traditional Primary Care Providers

The main difference between Internal Medicine Doctors and Family Medicine Doctors are that Internal Medicine Doctors specialize in adults only. They do not see children. Family Medicine Doctors can see the whole family so if you have children and you all get sick, you could make several appointments back-to-back and have one provider see you all.

In terms of a Doctor vs. a Nurse Practitioner, Nurse Practitioners have fewer years of education and training. In many states they also must practice under the supervision of a Doctor. Despite this, they are often very well-qualified to handle Primary Care needs and might also have more availability.

I generally suggest that for a first appointment or for a review of undiagnosed symptoms, seeing a Doctor yields the best result. Nurse Practitioners can be great for routine symptoms (cold/flus, strep throat, ear pain, etc.) and for follow-up appointments.

Step 1 – Who is In-Network?

Log into your health insurance company’s website and research which doctors are in-network AND are accepting new patients.

You’ll want to decide whether you want to see a doctor close to your job if you commute to the office or close to home. Keep in mind that Primary Care Doctors often have very little availability so you’ll likely be seeing them only for Annual Wellness Exams and non-urgent care.

You will also want to think about whether you want to see a Doctor in Solo Practice meaning it’s just them or a Doctor in a group practice. In my experience, I’ve seen more Internal Medicine Doctors in Solo Practice whereas Family Medicine Doctors generally are in group practices.

You will also want to think about whether you want to see a Doctor in Solo Practice (it’s just them) or a Doctor in a group practice. In my experience, I’ve seen more Internal Medicine Doctors in Solo Practice whereas Family Medicine Doctors generally are in group practices.

There are pros and cons to each Practice Model:

• Solo Doctors – Have a lot more control over how they run their practice. They are more likely to be customer-service oriented as they are directly responsible for the success of their medical business. The may have more availability as they often do not pay for advertising.
• Group Practice – High-level of bureaucracy can mean great doctor but lots of office red tape. You can see other providers if your doctor isn’t available, and they generally offer after-hours support or extended hours. Sometimes group practices will have on-site services such as phlebotomist to draw blood or imaging such as X-Rays.

Insurance websites have very little information regarding the doctor’s background and profile so pick at least five doctors that are in-network that seem like they might be a good fit.

Step 2 – What Would Make a Good Doctor For You?

Now that you have some names, think about key traits you want in a Primary Care Doctor. Are you looking for someone who is warm and nurturing, with an excellent bedside manner? Or do you prefer your doctors to be more direct and less personal?

What age are you looking for? Do you want someone with years of experience and wisdom but may be closer to retirement age? Or are you looking for someone new to doctoring who can hopefully be you doctor for years to come and may bring fresh ideas?

Do you have a particular gender you prefer? What about cultural background? Language preference? Married? Unmarried? Kids/no kids? LBGTQ+ friendly?

Studies show that finding a doctor that more similarly matches your personal experience can create better care outcomes.

Read more about this here:

• Physician-Patient Race-Match Reduces Patient Mortality
• Does it Matter if Your Doctor Looks Like You?
• Impact of the Doctor-Patient Relationship

Step 3 – Research Your Doctor

Perhaps the most important and often missed step when picking a Primary Care Doctor…

GOOGLE THEM.

Start with your list of five names and google each one of them.

Find their business profile, which should include their bio, picture, education, any publications they authored. Think of them as a consultant that you are looking to hire, and read their profile from that perspective – Would you hire this person?

Things I like to look for in a doctor’s profile:
(And yes, this sounds like you’re trying to find a date but in a way, this person will be there when you need them the most hopefully, so yeah! It’s kind of like dating!)

• How does their profile picture look? Do they look open and inviting? If they are smiling, does it look genuine? Look at their eyes, do they seem engaging?
• How does their profile read? Do the words resonate with you? Are you finding yourself in agreement with them and how their profile is worded? (Yes, some doctors may not write them but they definitely gave their approval).
• Do they appear to meet your criteria for traits you are looking for in a doctor?

After looking at the doctor profiles, select three (3) that you really like and think might be a good fit. If you have extra time, you can further google these names and look for online reviews. I really take reviews with a grain of salt, though, because everyone has different needs and just because one doctor wasn’t a good fit for someone else, doesn’t necessarily mean they won’t be a good fit for you.

The only exception to this is if the reviews mention that the doctor has no bedside manner, was rude, horribly late, or if lots of people comment that this doctor’s treatment plan didn’t work or was harmful. Those are red flags and it’s probably wise to pick someone else.

If any of the doctors you selected is in a group practice, make sure to review all of the doctors and nurse practitioners in the group and see if there is at least one other provider with whom you may be interested. It is likely that your selected doctor may not be available and you’ll need to make an appointment with someone else.

Step 4 – Think About What Kind of Appointment to Make

Before you even make your appointment, it’s a good idea to think about what kind of appointment would best fit your needs.

If you are establishing care for the first time (meaning you do not have a doctor anywhere else), you’ll likely need a New Patient Appointment. You can sometimes combine these with an Annual Wellness Exam, and doing so could cover some if not all of the costs.

If you are considering transferring care vs. establishing care (meaning you already have an established relationship with another Primary Care Doctor), you could see if this new doctor accepts Consultation appointments or just a general office visit. These types of appointments will allow you to meet with the doctor before transferring care.

Because there is a shortage of Primary Care Doctors in the U.S. right now, many offices will not allow you to schedule a Consultation appointment. They will want you to schedule a New Patient Appointment but it’s worth asking, especially if the doctor is a Solo Provider.

Appointment Length

Before you call to schedule, think about how much time you need for the appointment. Most New Patient Appointments are for 30 minutes. Follow-ups are generally 15 minutes. You can ask for an appointment of a different length by discussing your needs with the scheduler. The more complex your needs, the longer the allowed appointment time.

Here’s a reference guide for allowable appointment times and what makes an appointment basic vs. complex – AAAAI’s Reference Guide for E/M Coding.

Generally, complex needs include lots of different symptoms without a diagnosis (think: headache, chest pain, stomach upset all together) or chronic conditions that are uncontrolled.

Complex appointments with their longer length can also be harder to schedule, so an alternative is to break up your concerns into separately scheduled shorter appointments.

his can really only work if you have very separate issues. For instance, you have frequent headaches and shoulder pain. You could do a shorter appointment for your headaches and another appointment for your shoulder pain.

**Keep in Mind** that a longer appointment length means a higher cost if you have not met your deductible or have co-insurance.

If you are Cash Pay, it’s important to find out how much time you will have for the appointment and which CPT code they are using when scheduling the appointment. They should provide you with a Good Faith Estimate that will detail all of this information.

For more information, see What are the Most Common Family Practice CPT codes?

Step 5 – Make the Appointment

With your list of three (3) doctors, call and see who has the best availability for your schedule.

Best appointment times of day to avoid waits are: first appointment in the morning or last appointment before lunch. In general, the earlier in the day you can make the appointment, the better chance you have of an on-time appointment.

When you schedule, ask whether the doctor runs on-time or how long the wait might be (generally how far behind do they run).

After calling all of the places, pick a doctor and schedule that appointment!

Be sure to ask about any New Patient Paperwork and Online Portal Access.

Step 6 – Prepare for the Appointment

Gather Your Records

Now that you’ve scheduled your appointment you’ll want to start gathering up any lab test results, medical notes from hospitals/other doctors (you can also complete forms to have this sent later), imaging reports, etc.

This information can either be in printed form or the name and address of the businesses that have the information so you can complete the appropriate paperwork when you check-in to have the information transferred to your doctor.

If you have things printed and have a lot of lab values, I find it helpful to organize them in a three-ring binder with a lab cover sheet. I have a lab cover sheet template and I’m happy to provide it if you message me.

Also be sure to take the time to complete any necessary New Patient Paperwork or online forms.

If you are transferring care, you will need to ask the receptionist when you schedule your appointment for the form authorizing them to contact your previous Doctor and request your medical records. They cannot transfer your records without this signed document.

Prep Questions to Answer

In preparation for the appointment, I suggest asking yourself the following questions:

• What are my symptoms or concerns?
• Why am I seeking care now?
• What have I tried that hasn’t worked?
• What has worked?
• What results am I looking for? Diagnosis? Symptom reduction?
• What am I looking to get out of this appointment? A referral (specialist/rehabilitation therapy), lab testing, imaging, prescription, reassurance, a discussion, second opinion, etc.?

Appointment Agenda

(THIS IS FOR YOUR EYES ONLY)

Now that you have an idea of the goals of the appointment, it’s time to set-up the agenda that you will personally use.

Yes this is a business meeting! Medicine is a BUSINESS!

This isn’t something that most people do but that needs to change. You are paying for your doctor’s time and expertise and it’s important to run your doctor’s appointment like a meeting and having an agenda (even if it’s just for you). Having an agenda can make the appointment so much more productive!

I like to add my Agenda to the notes section of the appointment’s calendar entry on my digital device. That way I can’t lose it and I know it’s affiliated with that particular appointment.

Components of a Doctor’s Appointment Agenda

1. Elevator Pitch
   
   This is a brief (2-3 minute) monologue where you give some information about yourself (age, occupation, marital/family status), your personal medical history that’s relevant to today’s visit, any significant and relevant family disease history, and your goals for the appointment.

2. Top 3 Concerns
   
   Provide your three most important symptoms or concerns. Include how long they’ve been bothering you, how frequently they’ve been bothering you, what you’ve tried that hasn’t worked and what you’ve tried that has worked. Be sure to include if these symptoms impact your daily living and to what extent.

3. Discussion Steps
   
   Queue up ideas on what you’d like to discuss – whether that’s diagnosis ideas, follow-on testing/imaging, or treatment ideas. Be sure to highlight your concerns and link them to your goals and desired outcomes for the appointment.

4. Action Items/Follow-Up
   
   Leave this space blank if you’re filling it out on paper as you’ll want to record your notes.

Now that you have a plan for your appointment and hopefully all of your records organized, it’s time to wait for the appointment!

Appointment Day – Check-In & Wait

Now this likely will sound strange, but I like to ‘dress-up’ for my first doctor’s appointment.

Since medicine is a business and this first appointment is akin to a job interview (we’re interviewing our doctors), I personally like to dress for success and wear something that helps me feel confident. First impressions matter and at least for me, what I wear impacts how I feel.

You absolutely do you though!

Once you arrive, and check-in:

• Provide the receptionist any requested, completed forms
• Provide COPIES of testing/imaging and medical notes from other providers that you may have brought which need to be added to your chart
• If you asked for records to transfer (filled out appropriate paperwork ahead of time) make sure they transferred records
• Ask how long the wait is for your doctor
• Update any of your personal information if necessary

In terms of handling the wait, I prefer to keep off of headphones (save podcasts/videos/calls) while in the lobby so that I don’t miss hearing my name be called.

Once you’re back in the exam room waiting, you’ll know when the doctor arrives as the door will open.

Communicate and Advocate During Appointment

Usually the first person to meet with you will be either a nurse or a medical assistant. They will take your vitals and ask you “so what’s brings you in today?”

In an ideal world, they will convey any information you give them to the doctor prior to the doctor seeing you. However, with how fast offices move these days, that’s no longer a reasonable assumption.

Keeping this first meeting brief and giving them your top three concerns can help set the appointment up for success.

Once the doctor arrives, it’s time to start with an introduction and kick off your appointment.

SIDE NOTE: PLEASE DO NOT GIVE THE DOCTOR A COPY OF YOUR AGENDA.
Agendas are for your eyes only! They are to help you stay focused and organized.

Communication Tips for Keeping Things Focused and On-Track

In general, keep the discussion positive and assume good intent. Most doctors really care and want to be helpful!

Try to steer the conversation away from direct confrontation, ask questions and stay curious – misunderstandings happen frequently for both the doctor and the patient.

Your goal for the appointment should be to have an understanding of your next steps.

Conversation Starter Ideas and Redirects

• I’m concerned specifically about….
• I’m curious as to how [one of my top priorities] is being addressed in your proposed treatment plan?
• Can you help me understand why….?
• I’m confused, can you clarify…..?
• I’m not sure that I follow you, you lost me, could you try explaining it a different way?
• I’m concerned that I will not be able to afford your treatment plan, can you offer me alternatives or prioritize your plan?
• Something about your [proposed diagnosis] [proposed plan] doesn’t sit well with me, can we continue this conversation?
• Can we discuss alternative treatment ideas as what you are recommending isn’t an option for my lifestyle?
• Can you fill out this form for me?
• When should I expect to see results?
• When and how should I follow-up with you?

Another Approach is the Ask me Three

• What is my main problem?
• What do I need to do?
• Why is it important for me to do this?

A Word about Non-Adherent, Non-Compliant and Its Role in Future Care

It is very important that you feel confident that you understand and agree with your Doctor’s treatment plan. If you do not, it is best to continue the discussion until your questions are answered and you have agreement.

If you do not complete the proposed treatment plan, you can be designated as “non-adherent” or “non-compliant” by your Doctor and eventually dropped from their care.

Non-Adherent means that you are unintentionally not following the care plan – could be for reasons such as life got in the way of scheduling an appointment, medication or testing cost too much, you still have questions regarding the proposed plan, etc.

Non-Compliant means you are intentionally not following the Doctor’s proposed plan.

Ending the Appointment & Follow-Up Plans

Assuming the appointment goes well and you want this Doctor to be your Doctor, confirm that they too are willing to serve as your Primary Care Doctor.

If there is agreement, be sure to ask them when and how you should follow-up with them. You can also take this time to repeat back what you understand are your next-steps and ask them for confirmation.

Also, now that you have an established Primary Care Doctor, you will want to make sure to include their name on any other doctor forms (specialist appointments, lab/imaging testing) so that this doctor can receive your records.

Schedule Follow-Up Appointments If Necessary

As you leave, make sure that you have online portal access so that you can view the notes from today’s appointment, lab/imaging test results and be able to message your Primary Care Doctor if you have any follow-up questions.

If you had a Consultation Appointment and want to officially transfer care, ask the receptionist for the necessary forms to transfer medical notes.

Be sure to schedule any follow-up appointments and hopefully this guide helped you have a productive appointment!