Health Reform changed a lot of preventive care guidelines.  Some insurances cover at 100% – meaning there is no out-of-pocket costs but some insurances do not.  But what is PREVENTIVE care?  Not all routine blood tests are preventive, for example thyroid tests are usually not preventative.  Not all cancer screenings are preventative-example lung cancer is usually not considered preventive.  Not all “screening” doctors’ office visits are preventive.-maybe a total body skin exam by dermatologists are not usually considered preventative.

A screening test or visit MAYBE covered at 100% IF 1-the test, procedure or visit is widely accepted by the medical community as effective in preventing disease. #2 the patient fits within the gender, age or other demographic parameters of the preventative care recommendations and if the bill is coded by the billing office and processed by the insurance company correctly.  It is important to note that all three need to happen in order to fall under the preventive care label;.

A division of the federal government usually sets the standard of what is widely accepted by the medical community.  Not all screenings are appropriate for everyone and that can get complicated. Cholesterol screening for men is at age 35 or older.  For women it at 45 or older. So a 40 year old couple goes for their annual wellness visit and have their cholesterol checked.   His may be covered.  Hers may not be covered.

The billing and coding of claims is also a complicated process.  Insurance companies have codes that must be met on the bill for the claim to be processed as preventive and covered at 100%.  And those aren’t readily available with all companies.  An example-You may discuss your leg pain during your preventative visit but leg pain is not a preventative diagnosis.  If you bill the leg pain then the preventative may not process the claim as preventative but rather a visit for a specific medical condition.  Then the patient is expected to pay the copay and or deductible.

It’s real important when you have your annual wellness visit that you discuss with your doctor what your insurance covers as your preventative visit.  And that you know that information ahead of time.

  • Your annual Preventive Care visit with your primary care provider does not always include physicals.
  • Preventive Care Visits or Annual Wellness exams usually are more of a conversational visit so make out a plan of care for you each year.
  • Regular or routine office visits are for medication refills and review.  Follow ups for your medical condition that you have.  It could be every 3-4 months.
  • Sick Visits are just for that, to come in because you are sick.

It’s good to know the difference.