The Fine Line Between Preventive and Diagnostic

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The Patient Protection and Affordable Care Act (PPACA) dictates that preventive care be covered at 100 percent.  This is a great start to motivating Americans to get the regular check-ups they need; however, much confusion lies around what is covered and what is not.  There is a fine line between what physicians code as “preventive” and what they code as “diagnostic”.  It is helpful to know the difference between the two, so you can better plan for, or prevent, surprising and unexpected charges. 

Preventive care is defined as routine check-ups undertaken without any indication you are sick.  For example, if you are scheduled for your annual physical, and you indicate to the doctor you’ve been experiencing an ear ache, that check-up would turn into a diagnostic appointment.   What that means for you is the appointment is no longer covered at 100 percent and may be subject to a deductible or copayment.  To be sure an appointment is preventive, you would need to come to the doctor’s office not experiencing any symptoms and no reason to think you were unhealthy. 

Diagnostic care is defined as someone exhibiting symptoms that point to a health problem.  Examples include a persistent cough, pain or trouble breathing.  It is important to keep the line of communication open between you and your doctor.  Asking questions such as, “will this be covered as preventive care?” may be uncomfortable at first, but it can save you a lot of expense in the long run.  Making sure you understand what is covered and what is not before you leave the doctor’s office will eliminate unpredictable bills. 

Important Preventive Care Considerations:

• Grandfathered Plans:  If your employer’s health plan is “grandfathered”, preventive care may not be covered at 100 percent.  You will need to check with your company’s Human Resources Department for more specific information.
  
  
• Network Providers:  If your health plan has both in- and out-of-network providers, only in-network providers are expected to cover the preventive services.  If you see an out-of-network doctor you will likley be charged.     
  
  
• Office Visit Fees:  Your doctor may provide a preventive service for you; however, if another test is done, or a problem is found, during that same visit that is not considered preventive, then you will be charged.

Health care can be costly and confusing.  Keeping yourself educated will benefit tremendously and hopefully give you the confidence you need to have these important with your physician. 

Please share any experiences you have had ¾ good or bad ¾ relating to preventive care.  Or post your questions below.

Click here for a full listing of preventive services as defined by the Department of Health and Human Services.