What constitutes Preventative Care?

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unclescrooge
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What constitutes Preventative Care?

Post by unclescrooge » Fri Feb 17, 2017 7:28 pm

I went to see a new in-network doctor under my new medical plan, under which, preventative care visits are covered at 100%.

I just wanted an annual physician, and since I'm predisposed to certain medical conditions just make sure everything is under control.

I got the bill and I owe the full $154 for the visit plus a nominal amount for the blood work. Since the doctor coded the exam as a "full physical exam", this doesn't constitute preventative care.

While this quite a reasonable fee, I feel a bit cheated by the insurance company. Since I'm predisposed to certain conditions, shouldn't getting them checked out constitute preventative care?

Calls to health insurance (Cigna) or the doctor's billing department were pretty useless. Can someone please explain what constitutes a preventative care exam?

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dodecahedron
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Re: What constitutes Preventative Care?

Post by dodecahedron » Fri Feb 17, 2017 7:37 pm

Here is how ACA defines required preventative care:

http://kff.org/health-reform/fact-sheet ... lth-plans/

mur44
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Re: What constitutes Preventative Care?

Post by mur44 » Fri Feb 17, 2017 8:05 pm

Medicare defines Preventive Care as follows:

https://www.medicare.gov/coverage/preve ... vices.html

Medicare does NOT cover Annual Physical either.

Your SPD (Summary Plan Description) should define it.
Ask for your SPD.


Disclosure: I am a Certified Volunteer Medicare Counselor from NJ

brennok
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Re: What constitutes Preventative Care?

Post by brennok » Fri Feb 17, 2017 9:40 pm

The way I was always taught based off billing and insurance companies.

A preventative visit is essentially a healthy visit. Sick Issues aren't discussed and refills or medications aren't given. They review your medical history and run various labs.

Anything else turns the visit into a sick visit or non-preventative. You can do both on the same visit assuming they code it correctly. This is usually due to scheduling a physical and getting sick before the physical.

Most doctors in my experience don't bill a physical for the very first visit there. They don't know your history, and issues come up in discussions with the patient.

Now some doctors do a two part physical. The first visit billed as a sick visit they do the majority of tests including those that may not be covered under a routine diagnosis. The second visit is the physical where they review the lab results.

What are the codes they billed for your visit? You should have recieved an explanation of benefits from your insurance.

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unclescrooge
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Re: What constitutes Preventative Care?

Post by unclescrooge » Fri Feb 17, 2017 10:05 pm

mur44 wrote:Medicare defines Preventive Care as follows:

https://www.medicare.gov/coverage/preve ... vices.html

Medicare does NOT cover Annual Physical either.

Your SPD (Summary Plan Description) should define it.
Ask for your SPD.


Disclosure: I am a Certified Volunteer Medicare Counselor from NJ
Thanks.

According to the link, a one-time "welcome to Medicare" check up seems to be covered.

While I'm not under Medicare, I would think a "welcome to the practice" visit would be covered.
Last edited by unclescrooge on Fri Feb 17, 2017 10:07 pm, edited 1 time in total.

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unclescrooge
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Re: What constitutes Preventative Care?

Post by unclescrooge » Fri Feb 17, 2017 10:06 pm

dodecahedron wrote:Here is how ACA defines required preventative care:

http://kff.org/health-reform/fact-sheet ... lth-plans/
Thanks

MPAndy222
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Re: What constitutes Preventative Care?

Post by MPAndy222 » Fri Feb 17, 2017 10:37 pm

How old are you? If you have commercial insurance, an annual physical is supposed to be covered 100% per the ACA. Included blood work differs by the insurance company but should include glucose and cholesterol screening. Almost all plans still cover annual PSA testing too (if you are > 40). If you had other issues that were addressed the doctor may have charged another visit on top of the preventive E&M or placed a modifier on the bill. I don't think the cost is worth your hassle but you could ask what E&M code was used and if any modifiers were added to find out more about why it wasn't covered 100%

toofache32
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Re: What constitutes Preventative Care?

Post by toofache32 » Fri Feb 17, 2017 10:55 pm

The problem is that most patients don't understand how their insurance works in these scenarios. For the most part, this "free" visit is covered if you let your doctor check a few boxes designated by the insurance company. But if you bring up additional issues, then everything changes.

Here is the interesting part: As far as your actual health goes, the visit is not very helpful if you simply keep your mouth shut and don't deviate into other areas not covered by this visit. Insurance companies know that most patients approach these scenarios as "while I am here let me ask you about my...." which takes the financial burden off the insurance company. As I have said before, these insurance "gotchas" are by design and systematic.

In summary, if you are interested in having it for free, then don't say a word, don't ask questions, and go through the motions. But if you are interested in your health, then ask questions and pay a few bucks.
Last edited by toofache32 on Fri Feb 17, 2017 11:14 pm, edited 1 time in total.

outdoorsygal
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Re: What constitutes Preventative Care?

Post by outdoorsygal » Fri Feb 17, 2017 10:59 pm

This is correct ^^^
If you even ask about a separate health issue during the visit, or a possible issue, then it is no longer preventative care. It could be coded differently and you would be charged.

So pretty much, there is nothing FREE about it.

Mudpuppy
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Re: What constitutes Preventative Care?

Post by Mudpuppy » Sat Feb 18, 2017 1:38 am

As I learned the hard way, once you bring up a condition during a physical exam, it ceases to be preventative. In my case, it was a trip-acquired illness that was still lingering at the time of my physical. I was able to negotiate to have the standard physical blood-work re-coded as preventative. I ended up just paying for the office co-pay and the additional lab work ordered to check into why the illness was lingering. Now I just reschedule the physical if I'm incidentally sick at the time and I schedule normal office visits to discuss concerns about my chronic condition.

I also learned the hard way that my doctor's blood draw station no longer goes to the cheap, local laboratory and now goes to a local hospital, where they charge hospital rates. So now I take the lab slip a few miles down the road to the cheap, local laboratory's draw station, even though that means more time out of my day for the appointment. They must have gotten a few complaints about that, as there's now a sign up advising people that the draw station is hospital-affiliated.

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Pajamas
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Re: What constitutes Preventative Care?

Post by Pajamas » Sat Feb 18, 2017 2:28 am

You should either already have a copy of your subscriber contract or be able to download it from your insurance company's website or at a minimum ask them to mail you one. Then look at the section about preventive care and what is covered at 100% or without a copay and what the criteria are.

Everything does need to go smoothly with the documentation for it to actually be paid without any contribution from you. Most of the billing and payment is done by software electronically.

For instance, your plan may require you to specify a primary care provider. Your annual checkup may be covered in full if it is done by that provider. However, if you did not notify you health care plan about your choice of primary care provider, the visit might not be covered in full.

As another example, if you have a mammogram which is supposed to be covered in full as preventive care but the correct diagnosis code is not used, it may not be covered at 100%. Or if the correct procedure codes are not used, same thing. I have seen payment for a mammogram rejected completely because the provider incorrectly billed for two mammograms of the same breast rather than one of each breast. As soon as the claim was resubmitted correctly, it was paid.

Bfwolf
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Re: What constitutes Preventative Care?

Post by Bfwolf » Sat Feb 18, 2017 2:39 am

Everything said above seems correct to me. But in my experience, some docs are pretty cool about it and will handle some deviation (or maybe a lot of deviation) from the annual physical checklist and still just code it as a physical.

carolinaman
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Location: North Carolina

Re: What constitutes Preventative Care?

Post by carolinaman » Sat Feb 18, 2017 8:24 am

Medicare does not cover a physical but does cover an annual wellness exam. I am not sure exactly what the difference is other than one is covered and the other is not. I get an annual wellness exam which includes some blood work screening for many conditions, a discussion with doctor, prescription review/renewal and can raise any concerns that I have. I would assume if you are past a certain age, any insurance would cover a wellness exam.

Cigna should be able to clarify this for you.

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