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Preventative or Diagnostic: Am I Covered?

One of the cornerstones of the Affordable Care Act (ACA) is the ten essential benefits that include preventative services with no deductibles or copayments. The list includes an annual physical screening for a procedures such as a colonoscopy and a mammogram. But what if you go to your doctor for your annual physical and, at the same time, have the doctor look at your sprained finger?  Can this still be considered an annual physical? What if your physician suggests a subsequent appointment to update a screening? Is this part of your preventative services? Must all procedures be done in network?

Good questions. Maybe. Maybe not. Herein lies the confusion between preventative and diagnostic. And it’s not only insurance companies that may have differing opinions on the subject.

There is a long list of what the ACA considers preventative care. Many of these screenings are accessible through blood work and most insurance companies will cover one preventative screening or visit per year with no charge to the policyholder. It is when this care is considered to be diagnostic that charges begin to accumulate and uncertainty ensues.

A colleague recently had what would be considered a routine colonoscopy. He is over age 50, therefore this procedure should be a preventative screening. During the procedure, the physician found polyps and sent them to a lab for further study. The polyps were noncancerous. Yet, although these polyps were located during a routine screening, the service was billed as diagnostic and my colleague was billed $520 for an in network provider. This seems to be a “catch 22”–how could the polyps be identified if there wasn’t a preventative screening done?

Further question: if preventative services are covered at no cost to the individual, can the screenings be done anywhere? Health insurance carriers aren’t required to allow subscribers to obtain services from any provider. Individuals should expect to go to in network services or face additional out of network charges.

Preventative or diagnostic? Some insurers have distributed educational literature for their subscribers to attempt to simplify this question. Not easy to simplify.

For additional information, contact EAB HealthWorks.