Most organizations agree that preventive care is vital to help keep their employees healthy. And for those that follow the rules of health care reform, services that qualify as preventive are available to employees at no cost. However, there is still a lot of misunderstanding about what services are preventive.
“Doctors only bill visits as preventive if they meet certain criteria, but the average person doesn’t know what that involves,” says Amber Hulme, Medical Mutual Vice President, Central and Southern Ohio. “As a result, organizations might see employees skip preventive visits, not knowing they’re free, or get charged for a visit they thought was preventive.”
Smart Business spoke with Hulme about how to distinguish between preventive services and other medical care, why the difference is important, and how organizations can address misconceptions that might be preventing their employees from properly using the benefits available to them.
What services are considered preventive?
Essentially, preventive services are those performed for patients who don’t already have symptoms, injuries or other health problems. The physician decides what tests or screenings are right for the patient based on their age, gender, overall health status, personal health history, current health and other factors.
A visit can include a physical exam, immunizations, lab work and possibly X-rays. The goal is to keep patients healthy through early diagnosis.
How is diagnostic or medical care different?
Basically, if a patient goes to the doctor to diagnose, monitor or treat a specific illness, injury or a chronic health condition, it’s probably not going to qualify as a preventive visit.
Plus, any related services a patient might receive, including exams and blood tests, would likely be considered medical care, as opposed to preventive care.
Why does the difference matter?
Unless a plan was grandfathered under health care reform, many preventive services have to be available to employees at no cost. However, what is considered preventive isn’t always clear. Many lab tests and other procedures, for example, are only covered based on why and how frequently they are done.
Depending on the circumstances, the same test or service can be billed as preventive or diagnostic, or as routine care for a chronic condition. Even during a preventive visit, patients may have to pay a copay or coinsurance if the doctor ends up performing services that aren’t considered preventive.
It can definitely be confusing, but really it’s based on how providers submit the claims.
How would this actually work? Can you give an example?
Sure. Let’s say a person goes to the doctor to get a preventive colonoscopy. This person hasn’t had any problems in the past, but the doctor finds a polyp during the exam and proceeds to remove it. That’s still preventive. The follow-up colonoscopy, however, is going to be considered a medical procedure in terms of how the billing works. That’s because a problem has already been identified.
Another common example is a routine mammogram, which is preventive for women age 55 and older. But if a woman finds a lump in her breast and decides to get a mammogram, it would not be considered preventive because the symptom already existed. The same goes for women who have been diagnosed or received treatment in the past. Their mammograms would fall under routine chronic care.
What should employees be encouraged to do?
Organizations should make sure employees are familiar with how preventive care works under their benefits plan. Their insurance carriers can provide a list of all the preventive services available.
It’s also important to encourage employees to ask their questions when they go to the doctor, such as why a test or service is being ordered. That will help employees make sure they know how they will be charged and still get the care they need.
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