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Free Preventive Care Confusion

Preventive care services that have been more recently granted the status of “free preventive care” since the Affordable Care Act, can ultimately end up as a charge depending on the outcome of the service and the type of plan you have. Of course, as we pay for health insurance on a monthly basis, the services are more adequately described as no additional cost, as opposed to completely free. In order to keep track of each preventive visit and test, the provider sends a claim to the insurer, billing them for the service. The reimbursement takes the form of higher premium costs for policyholder and employers, though the service itself remains without a copay.

While federal law requires each of the U.S. Preventive Services Task Force-approved services to be observed by health insurers and providers, some confusion may arise. Despite the fact that the law has been in effect for two-and-a-half years, there is still clarification needed on various aspects of the ACA. Preventive care is one of the more simple facets, though three main sources of misinformation can result in being charged extra for preventive care.

According to an article from 9 months ago that is still apparently relevant, many policyholders who receive bills for routine visits are unclear as to whether or not their insurer is covering the cost. Knowing your plan and internalizing the health care law are essential for full comprehension of preventive care. The ACA requires all plans to cover certain services for free, which should be listed in your schedule of benefits. However, there are still ways you can end up with an additional charge. Here are the key reasons why preventive care and billing are misunderstood.

Billing Code Issues

A good example of where confusion in billing often arises would be receiving a mammogram, which is a preventive service covered by all health plans. However, the billing code could indicate the mammogram was a diagnostic service, therefore resulting in a bill. Preventive care is not to be billed, while diagnostic care can be. What distinguishes the two is that preventive care is intended for those who appear to be healthy, as a precaution. Diagnostic care is defined as care given to patients to determine the root of their symptoms.

One service can be in either category, though it is entirely dependent on the health status of the patient. A woman who is in seemingly good health receiving a mammogram should be billed for a preventive service. A woman who received the service after noticing a lump in her breast should be billed for diagnostic care.

Clarifying this to a patient is very important, as they may see a service on the list of free preventive care benefits and assume it will not be charged if they are experiencing symptoms of an illness or condition. As a patient and health insurance policyholder, it is necessary to ask your doctors whether a service will be billed and what category it falls under.


Preventive Services Turn Into Diagnostic Care

Another example would be when a patient reaches the appropriate age where a colonoscopy is suggested as a preventative service. If the patient had no symptoms and went to the physician as recommended by their health plan, and the test results show nothing irregular, it is a free service. The patient’s insurer would be billed, and all is well.

Conversely, suppose the test results came back irregular and a polyp was discovered, and the doctor decides to remove the polyp for further screenings. Having received an additional procedure and follow-up testing, this goes beyond preventative care. The service is then considered diagnostic, and therefore the patient should expect an additional bill.


Out-of-Network vs. In-Network

A fairly typical experience for individuals with health insurance, non-network providers charge more for care, including preventive, than your plan’s network. As you can see from a basic outline of benefits with in-network and out-of-network services side-by-side, out-of-network preventive services are not covered in full. Though it may slip your mind, it is crucial to keep in mind the difference between in and out of network benefits. Each plan varies in its approach to out-of-network coverage, though unfortunately no services are covered at 100 percent when roaming to non-network providers.

Below is a section of a plan brochure from Cigna, indicating their preventive care coverage.

Service                                               Network                                               Non-Network


Make sure you understand your plan and your schedule of benefits before receiving care, and certainly before beginning a dispute with your health care providers or insurance company. It is also the job of the federal government and the health care system to be more clear on what is covered and what will not be. No one can assume a patient knows exactly what to expect. As a patient, you can inform yourself with the knowledge given by your plan so to avoid confusion regarding preventive care.