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Since the introduction of the new health care law in 2010, numerous in-network preventative services have been approved for 100 percent coverage under any health plan. Whether you’re on Medicaid or insured privately, if you use a network provider to get annual exams and age-appropriate screenings, you will not be charged.

However, there have been certain instances when patients believe they are receiving a form of care that should be covered in full, then are later billed for that service.

Several services that the Affordable Care Act requires health plans to provide for free may cross into the diagnostic realm. Therefore, that claim will be billed as a diagnostic service and not be paid for in full by the insurer.

Recognizing the difference between seeking routine prevention and receiving care for an existing problem is key in anticipating your medical bills. A common example of this mix-up is found in cancer screenings. While they are preventive service, if you go to the doctor suspecting a lump, tumor, or other problem, your tests are considered diagnostic.

Know Your Services

It is understandable that seeing a service listed as “free” could cause a patient some confusion when the context of that service varies. But when your provider submits a claim to your insurance company, the billing codes are entirely different for a preventive mammogram and a diagnostic mammogram.

What if you are susceptible to recurring episodes of the same condition? Many individuals who have had cancer or a precancerous condition struggle with abnormal cells forming again after their removal. Does your increased risk make each visit preventative or diagnostic?

From what we see, if you are unsure of your condition’s status, you don’t feel any physical changes, and you are going in for a visit as prescribed by your doctor (once every six months, year, or however often), it will fall under the preventative category. If you call your doctor for an appointment because you’ve detected symptoms, you will be billed for a diagnostic service.

How to Remedy the Confusion

Always ask your provider which type of claim they plan to file before you leave the office. Understanding your claims by communicating with your doctor helps you avoid any surprises in the future.

There are times when you might go in for a preventative visit and happen to mention another health concern while you’re with the doctor. If the provider performs another test or service that isn’t related to prevention, you should ask how that visit is going to be billed.

This is a common problem that can be easily cleared up with a small amount of effort before you find yourself billed, then call your insurer and attempt to file an appeal.

For more guidance on claims, insurance, and billing visit echealthinsurance.com/health101/claims/.


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