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. But what care is consideredpreventive? Not all cancer screening is preventive (e.g. lung cancer screening is usually not considered preventive). Not all routine blood tests are preventive (e.g. thyroid tests are usually 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?
A screening, test, procedure or doctors’ office visit is considered preventive and covered at 100 percent 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 preventive care recommendation and (3) the bill is coded by doctor’s 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.
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.”
Recommendations for Adults
Recommendations for Children
Many of the recommendations from the USPSTF are to NOT screen because there is not sufficient evidence that the screening helps or that the screening may actually be harmful (yes, screening can be harmful.)
The USPSTF also provide a list of recommendations that are considered strong (i.e. Grade A or B) and 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 everyone… and it can get complicated. Let’s take cholesterol screening 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. So a 40-year-old couple may go in for their annual physical and have their cholesterol checked. The end result? 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.” I would also add that the doctor must document that increased risk in the medical record, because it is likely that a copy of that record will need to be sent to the insurance company in order for the claim to be processed correctly. You can’t just say you are at an increased risk, it has to be documented by the healthcare provider.
On top of all this, in my opinion, I would say that most physicians do not know all of the demographic parameters around preventive care. Accordingly, 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… at least initially. You and your doctor will likely 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:
Unfortunately, the billing and claims processing in healthcare is so complicated that errors frequently occur. The insurance company has codes that must be met on the bill in order for it to be processed as preventive and covered at 100 percent. The code that frequently needs to be used for a preventive doctor’s office visit is the ICD-9 diagnosis code of V70, which means ‘Routine General Medical Examination’ (aka Health Checkup). The challenge is that if during the preventive doctor’s visit, the patient or the physician find a specific medical issue or complaint (which is the whole point of the visit right? To find stuff), then the physician will likely also include an ICD-9 diagnosis code for that issue (e.g. Low Back Pain or Lumbago is 724.2) on the bill and the insurance company will not process the bill as ‘prevent’ but rather as a visit for a specific medical condition. The patient is then expected to pay the copay or portion of their deductible.
All of this is rather confusing and time-consuming for all parties involved—the patients, doctor’s offices and insurance companies. At Compass we help our members sort through this on a daily basis. It is complicated and it is frequently a mess.
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.
What do you think? What have you done in the past to ensure that your preventive care is covered at 100 percent?
To view at 30-min webinar by me on how Cost and Quality do not necessarily correlate in healthcare click on the link below: