Preventive Care -Don’t Assume You’re Covered

One of the selling points of the Affordable Care Act was the promise of free preventive care. Indeed, a reading of the Explanation of Benefits (EOB) from your health insurance policy most likely lists a fully-covered annual “well” visit for individuals and family members, with women usually granted an additional visit covered at 100% with an OB/GYN if they have a separate Primary Care provider.

The hitch comes when your health care provider chooses the code that designates the reason for your visit. Let’s say the office requires an annual appointment in order to obtain a renewal for your blood pressure medicine. You see it as preventive, eligible for a cost free visit. You’ve been vigilant in checking your pressure at home, and take your medicine as prescribed every day. You’ve had no events, no heart attack, no stroke, no chest pain.

The doctor, however, may view checking your hypertension as diagnostic, as it may require a change in dosing of your current meds, or the addition of, or a switch to, a drug from an entirely different class of medications. Even if your BP is perfect, the doctor may feel your previous diagnosis of hypertension precludes coding your visit as preventive. To add to the patient’s perception of being misled, unless your doctor or his/her staff is savvy enough re the EOB language in your insurance policy, AND proactively informs you that you may be liable for the entire cost of your visit, you may not grasp the intricacies of medical coding until you receive a bill in the mail for the full amount.

You can call your insurer, and their customer service rep may go to bat for you with the doctor’s office, or they may refer you to a designated Health Advocate to intercede on your behalf. But, if the doctor sticks to his/her guns, you’ll be paying out-of-pocket. In today’s world of a shrinking number of doctors in private practice, your physician may be subject to the rules of the medical group that employs him/her, regardless his/her personal feelings.

Don’t feel vindicated if the bill shows an “insurance discount” subtracted from the total. That “chargemaster” amount is part of the negotiated billing contract between insurance companies and providers (doctors/medical groups/hospitals). A provider may well try to push that full price onto cash-pay patients, but negotiations with those individuals usually include a “generous” offer to reduce the bill to the rate charged insurance companies.

At the very least, insurers and providers should be transparent about the practice of how a “well” or “preventive” visit is defined. Patients should not be expected to play guessing games when scheduling an appointment, or be subjected to “bait & switch” tactics that stick them with a bill for services they were led to believe would be provided at no charge.

This disconnect between the language of the law and its interpretation when applied in the real world, is  one more reason health care dollars should be controlled by the person receiving care. Customer satisfaction should depend on the quality and cost-effectiveness of care as measured by the patient, not by lawyers or marketing-execs representing insurers and providers.