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December 22, 2011 at 10:07 AM
The health insurance industry is still weighing the benefits of a new federal requirement that prevents doctors from billing patients or charging a co-pay for recommended preventive care.
On the one hand, by encouraging people to make regular visits to the doctor, we may save lives and money by catching illness in their early stages. Yet it is certainly misleading for anyone to expect preventative care to simply be “free.”
Every “free” preventive doctor visit and “free” preventive test is billed by providers to insurance companies. Those costs are passed on to policyholders and employers in the form of higher insurance premiums.
The other issue is that should be addressed is when patients are billed for care that they expected to be covered at no direct cost to themselves as preventive care.
As a health insurance broker and president of the New Jersey Association of Health Underwriters, I’ve been answering numerous questions from policyholders who can’t understand what is free and what isn’t. They are skeptical when they receive a bill for routine visits, wondering if their insurance company is already fronting the cost.
This isn’t as if people are acting less than honest. Here are the culprits:
1. Billing code confusion.
You may think of a mammogram as a preventive service, but if the billing code for a diagnostic service is submitted to the insurance company, you will get a bill. I spend considerable time on the phone, discussing this issue with policy holders, medical providers and insurance companies.
The key to understanding the difference between preventive care — which should not be billed — and diagnostic care, which is eligible for billing — is this: preventive care is given to people who are apparently healthy. It is precautionary. Diagnostic care is given to people to determine the cause of their symptoms.
The same service can fall under either category. A mammogram given to an apparently healthy woman should be billed as preventive. A mammogram given to a woman who has noticed a lump in her breast should be billed as diagnostic.
