Preventive care covered at 100 percent, but what is considered preventive?

December 5, 2018

With health reform, many people are now aware that preventive care is covered at 100 percent–meaning there is no out-of-pocket cost to the patient. However, what care is considered preventive? Not all cancer screening is preventive (e.g., lung cancer screening is usually not regarded as preventive). Not all routine blood tests are preventive (e.g., thyroid tests are generally not preventive). Not all ‘screening’ doctors’ office visits are preventive (e.g., total body skin exams by dermatologists are usually not considered preventive). So what is preventive and who decides?

Several factors make a screening, test, procedure or doctors’ office visit preventive and covered at 100 percent. First, the test, procedure or visit is widely accepted by the medical community as effective in preventing disease. Second, the patient fits within the gender, age or other demographic parameters of the preventive care recommendation. Finally, the bill is coded by the doctor’s office and processed by the insurance company correctly. It is important to note that all three should happen to fall under the preventive care label.

  1. The test, procedure or visit is widely accepted by the medical community as effective in preventing disease: A division of the Federal Government—within the Department of Health and Human Services—called the U.S. Preventive Services Task Force (USPSTF) usually sets the standard of what is widely accepted by the medical community.  According to the USPSTF’s website: The USPSTF is an independent panel of non-Federal experts in prevention and evidence-based medicine and is composed of primary care providers (such as internists, pediatricians, family physicians, gynecologists/obstetricians, nurses, and health behavior specialists). The USPSTF conducts scientific evidence reviews of a broad range of clinical preventive health care services (such as screening, counseling, and preventive medications) and develops recommendations for primary care clinicians and health systems. These recommendations are published in the form of “Recommendation Statements.” Several of the recommendations from the USPSTF mention that there is not sufficient evidence that the screening helps, and points out some of the risks of screening. The USPSTF also provides a list of strong recommendations for preventive health care  (and grades them A or B). These are typically covered at 100 percent as dictated by Health Reform.
  2. The patient fits within the gender, age or other demographic parameters of the preventive care recommendation: Not all screenings are appropriate for every person. For example, cholesterol is tested for by a simple blood test usually performed at the doctor’s office or lab. For men, the recommendation is to screen at age 35 or older. For women, the recommendation is to screen at age 45 or older.  A 40-year-old couple may go in for their annual physical and have their cholesterol checked. The husband will not have to pay for his test, but the wife will have to pay for hers. Now the physician can screen for high cholesterol at an earlier age, but according to the USPSTF the patient must be at an “increased risk for coronary heart disease.” Ideally, this should be documented by your doctor to show to the insurance company. Your doctor may say “this is preventive,” but if according to the USPSTF standard it is not, it will likely not be covered at 100 percent. You and your doctor may have to appeal to the insurance company and justify the rationale for going outside of the USPSTF recommendations.
  3. The bill is coded by the doctor’s office and processed by the insurance company correctly: The insurance company has codes that must be met on the bill for it to be processed as preventive and covered at 100 percent. The challenge is that if during the preventive doctor’s visit, the patient or the physician find a specific medical issue or complaint, diagnosis code for that issue (e.g., Low Back Pain) will be on the bill. As a result, the insurance company may not process the bill as ‘prevent’ but instead as a visit for a specific medical condition. The patient is then expected to pay the copay or portion of their deductible.

Helpful hints

One helpful hint would be to print out the shortened list of preventive services from the link above and actually have the doctor check off which ones he or she is going to do and make sure that they follow the parameters of the USPSTF. Another tip is to tell the physician you would prefer your visit to be considered ‘preventive’ and coded as such.

This can be confusing and time-consuming for all parties involved—the patients, doctor’s offices and insurance companies. At Alight, we help your employees sort through this on a daily basis with our healthcare navigation services. 

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