Preventive care, and why it sometimes generates a bill

Most health plans are required to cover a specified list of preventive services without cost sharing when delivered in network.

The list is defined by reference to recommendations from designated bodies, and it includes screenings, immunizations, and preventive services for children and for women.

People still receive bills for these services regularly, and the reasons are specific.

The screening-to-diagnostic conversion

The most common cause.

A service ordered as screening — for someone with no symptoms and no relevant history — is preventive.

The same service ordered because of symptoms, or to follow up an abnormal finding, is diagnostic, and diagnostic services are subject to normal cost sharing.

The classic example is colonoscopy. A screening colonoscopy is preventive. If a polyp is found and removed during the same procedure, older billing practice frequently converted it to a diagnostic procedure with cost sharing.

Guidance and rules have clarified this in ways generally favorable to patients, including provisions regarding polyp removal during a screening colonoscopy and, more recently, follow-up colonoscopy after certain non-invasive screening tests.

If you receive a bill in this situation, it is worth challenging with reference to the applicable guidance.

Other reasons a bill appears

Out-of-network provider. The requirement applies to in-network services. A preventive service from an out-of-network provider is not protected.

This includes the laboratory. A blood sample drawn at an in-network office may be sent to an out-of-network laboratory, generating a bill.

Ask which laboratory is used and confirm it is in network.

Additional services during the visit. A preventive visit that also addresses a new problem generates a separate evaluation and management charge for the problem, which is subject to cost sharing.

This is legitimate billing. If you raise a new concern during your annual physical, that portion is not preventive.

If you want to keep the visit purely preventive, raise other concerns at a separate appointment.

Frequency limits. Preventive coverage applies at specified intervals. A second screening within the interval is not covered as preventive.

Age and risk criteria. Many recommendations apply to defined age ranges or risk groups. A service outside those parameters is not required to be covered without cost sharing.

Miscoding. The service was preventive but was coded incorrectly.

This is common and correctable. Ask the provider to review the coding and resubmit.

Grandfathered plans. Certain plans in existence before the relevant legislation and unchanged since may be exempt from some requirements. This applies to a shrinking number of plans.

What the covered list includes

Broadly, and subject to the specific criteria:

Screenings for various cancers at recommended ages and intervals. Blood pressure, cholesterol and diabetes screening. Immunizations per recommended schedules. Screening for certain infectious diseases. Depression and behavioral health screening. Tobacco cessation interventions. Obesity screening and counseling. Well-child visits and developmental screening. Contraception and related services, subject to certain exemptions. Prenatal care and breastfeeding support and supplies.

The list is updated as recommendations change, generally with a delay before plans must implement changes.

Practical steps

Confirm before the appointment that the service is coded as preventive, that the provider is in network, and where any specimens will be sent.

Say explicitly at scheduling that you are coming for a preventive visit.

Check the explanation of benefits when it arrives and compare the coding to what you understood.

If billed, ask the provider first to review the coding, and then appeal to the insurer if the coding was correct but the benefit was applied wrongly.

A substantial share of these bills are resolved at the first call.

The broader point

Preventive coverage without cost sharing exists because cost is a barrier to screening, and screening detects conditions when they are treatable.

An unexpected bill discourages the next screening, which is why these disputes are worth pursuing rather than absorbing.

They are also, in the majority of cases, resolved when raised.

General information about insurance concepts, not insurance or medical advice. Coverage requirements, recommended services and plan obligations change. Consult your plan documents, your provider and your insurer.