Mind Your P's and D's: Preventative Versus Diagnostic Care

With the surging popularity of high deductible health plans (HDHPs), many employer-based and even some individual policies include the exception of an annual physical or wellness exam that is covered in full and not subject to the deductible, coinsurance, or co-pay. This exception is designed to encourage members to seek recommended health screenings, rather than forgoing them due to the high cost burden of paying upfront and out-of-pocket for what many might regard as a non-priority . Members are understandably aggravated when they are billed for services they thought were for preventative purposes only and thus, covered in full by their health plan. Understanding the difference between preventative and diagnostic care is key to minimizing the impact on your wallet.

Preventative care includes examinations and/or services performed in the absence of signs and symptoms of illness. Diagnostic care refers to examinations and/or services performed to diagnose a condition when the patient presents with signs and symptoms. Although a preventative exam and a brief, problem-focused exam can be done simultaneously, most insurance plans will not pay for both at the same time. Moreover, healthcare providers often receive less reimbursement for providing time-intensive, preventative care than they do in conducting a 10-minute, problem-focused visit. They have little incentive to bill exclusively for preventative care even if it comprises the majority of a given visit. What does this mean for the discerning patient?

If your insurance plan covers preventative care at 100% and you schedule an appointment for an annual physical exam and express no health complaints, your claim should be billed as preventative, and your plan should pay the provider in full. You incur no costs for the services. On the other hand, given the same scenario, if you express complaints and especially if services are ordered to address those complaints (e.g., specific laboratory or radiology tests), your entire visit is now considered diagnostic, and the deductible, coinsurance, and/or co-pay will apply to all billed services.

Clever, yet unsuspecting, patients may assume they can address health problems at their “free” preventative care visit and avoid the time and expense of additional visits, but this practice is a gamble because insurance companies carefully review claims that fall outside designated parameters (i.e., CDC guidelines in the case of preventative care. If your claim reflects any irregularities, the insurer may ask for clinical documentation to review the claim further or in all likelihood, will deem the visit diagnostic and pay accordingly, which means you will receive an EOB (Explanation of Benefits) showing that you now owe a portion of the allowed amount to the provider. So much for that free visit!

What happens if your plan covers preventative care at 100% and this is what you received, but your EOB says you owe a portion of the claim? Contact your health care provider’s billing department and confirm that the claim was submitted with the appropriate ICD-9 (diagnosis) and CPT (procedure/service) codes indicating preventative care. Health care payers and providers use these codes to communicate diagnoses and services performed in a concise format. One omitted or transposed digit or simply the wrong code can cause a claim to be denied or paid differently within the electronic claims processing system. Before leaving your provider’s office, get a copy of the requisition or charge sheet that will be used to bill your insurance company. It contains the ICD-9 and CPT codes for your visit and can prove invaluable in sorting out billing errors with the healthcare provider and insurance plan.