When free preventative care isn't free

Calculating when a medical test will be paid for as 
a preventative service is complicated

Many health insurance plans now feature free preventative care. The concept was originally introduced as part of the HMO philosophy that early prevention would save patients from more serious health problems later.   I was surprised to learn that there is actually a debate as to whether preventative care saves lives or is too costly.

This is not the place for this discussion but you can read the arguments for and against  preventative care at other sites.

What we are considering here is what is considered preventative care as defined by a health insurance policy. What seems like  a very simple question, unfortunately, has a very complex and sometimes incomprehensible answer.

Why is it such a difficult question to answer?  Because the answer depends on two different criteria.

1. the definition as printed in the policy language of your insurance plan

2. the state in which you live

The policies written by different insurance companies will vary.  These are contracts and each company writes their own.  Many plans advertise that they include an annual physical for men and children and two for woman because of the OB/GYN physical. It's called preventative care.

State mandates may require that certain tests be included in annual physicals. These  generally include all the childhood immunizations, PSA tests for men,  and Mammograms and PAP tests for women. In 2007 colon rectal screening  for people over 50 was mandated by 21 states.

It is the last test which has been causing the most problems in determining what a patient may have to pay.  A colonoscopy is the examination of the large colon and distal part of the small bowel with a CCD camera or fiber optic camera on a flexible tube.

Many insurance companies do include the colonoscopy as a preventative test and as such should be 100% paid by the insurance company.  But this is where it gets really confusing.  If a colonoscopy is done and it is completely clear, the procedure will almost always be paid as part of preventative services.

But, what if the doctor finds small polyps and removes them?  A colonoscopy can remove polyps as small as one millimeter or less. Once polyps are removed, they can be studied with the aid of a microscope to determine if they are precancerous or not.

Now it gets really  tricky. Once something is discovered the procedure immediately switches from a preventative service to a diagnostic.  A diagnostic service is not preventative and thus not paid as a preventative service.

Did everyone follow that?

If a colonoscopy does what is is supposed to do, that is, remove small polyps before they become something worse, then the procedure is not preventative and is not covered by the free preventative care provision of the insurance policy.   If the policy has a deductible for diagnostic services, the colononoscopy will now be put toward the deductible and depending on the amount of the deductible, the patient may end up paying the whole amount for the test.

It’s not just colonoscopies that are subject to this convoluted accounting.  PSA tests for prostate cancer screenings can change from preventative to diagnostic if something unusual is found.

Mammograms and PAP smears are also vulnerable. Even additional blood tests done as part of a routine physical may become diagnostic and not be paid.

Sometimes, charges received by a patient for these tests are merely miscoded when the doctor submits the bill. If a patient receives a bill for a service they thought would be covered as preventative, after their doctor has confirms that the test found nothing, the patient should immediately call their insurance company and question how the bill was submitted – as preventative or diagnostic.

Always check the bill and ask questions. But be aware that these preventative tests have been known to switch species and become diagnostic. If that happens, the patient may be liable for the bill.