It may have already happened to you: You came in for your annual exam, got the vitals checked, everything looks good, and you had some questions about that persistent sniffle. Pretty straightforward stuff. Then you get the health insurance bill. What's going on? You think, preventive visits are covered 100%, no deductible, right!?
It's true, the Affordable Care Act mandates that preventive care services are completely covered by health insurance, meaning that patients do not have out-of-pocket costs for a preventive visit. However, there is some confusion as to what a 'preventive' visit is, and how it differs from a ‘problem-focused’ visit. The difference between the two matters when it comes to your coverage and what you will pay out of pocket.
A Preventive Care visit
- Occurs once a year
- Does not require any payment
It involves a review of your overall health, which includes:
- Updating your medical history, including medications, family history, medical and surgical history.
- Assessing your personal health risks including family history, tobacco and alcohol use, nutrition, activity level, and weight.
- Measuring blood pressure, height and weight.
- Discussing an individualized preventive screening plan, which may include cancer screening, lab tests, and imaging studies.
- Reviewing the need for immunizations, such as tetanus.
A Problem-focused visit
- Involves the diagnosis and treatment of a condition or illness
- Requires more detailed discussions about a specific problem(s), possibly involving diagnostic tests and/or a physical exam
- Generates treatment plans to address new symptoms or manage a chronic illness.
Because it involves care (as in the diagnosis and/or treatment) of a problem (as in a condition or illness), it will require:
- A co-pay,
- And the possibility that the visit charge may be applied to your deductible,
- And if your deductible is satisfied, a co-insurance payment, depending on two variables: the services provided and your health insurance benefits.
The confusing gray area
During a preventive care exam, you and your clinician may re-evaluate existing medical problems or address new issues or symptoms. You may incur a charge for such a discussion depending on the complexity of the issue, the need for diagnostic tests and the extent of the treatment.
“At GreenField we provide comprehensive care,” says Dr. David Shute, GreenField Health’s Medical Director. “Annual visits include a preventive visit and often include a re-assessment of existing medical conditions and evaluation of any new problems.
“We believe this is an efficient use of a member’s time and the correct way to practice medicine,” he continues. “If we provide a significant amount of evaluation and management of a problem at an annual visit, we will bill for that service as well.”
What’s a patient to do?
You can do a few things to prepare for your preventive care exam:
- Know what your health insurance benefits are for both preventive and problem-focused visits.
- Draft an ‘agenda’ for your appointment. Do you have any medical issues that are new? Or other significant health concerns?
- Bring a list of medications and nutritional supplements that you take.
- Discuss any financial concerns about your health care with your clinician.
- Be prepared for a co-pay and possible deductible amount and/or a co-insurance charge because there may be symptoms or issues that warrant further investigation and treatment.
“We want to work with you to identify and treat active problems promptly—to keep you healthy and to help you live well,” says Dr. Shute. He adds that, while GreenField Health can assist with billing questions, only your health insurance provider can provide the most definitive answers about what your plan covers.
Please contact us if you have other questions about insurance billing matters. For billing questions, please contact Michelle Wing, firstname.lastname@example.org. For medical questions, please send a secure message to your GreenField Health clinician.