The Type of Care You Get Can Impact Your Out-of-Pocket Costs

Your routine visit with your primary doctor may include preventive care and diagnostic care. While you may not notice much difference between these two care types during your visit, your doctor will bill the health insurance company differently for these services, and the health insurance company will pay for them differently.

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Most health insurance plans cover certain preventive services at no cost to you, provided the doctor has billed the insurance company for “preventive services”. However, when you obtain diagnostic care, you will usually pay a deductible, co-pay, or co-insurance. Understanding the difference between preventive care and diagnostic care can help you know what to expect to pay.

What's The Difference Between Preventive and Diagnostic Care?

What Is Preventive Care?

Preventative care includes the health services you obtain to stay well and avoid developing life-threatening conditions. During a preventive care visit, your doctor may review your likelihood of developing a condition such as high blood pressure or diabetes and discuss what you can do to lower your risk. This type of care also includes routine checkups, preventive screening tests, annual wellness visits and most immunizations. The purpose of this type of care is to catch potential problems before symptoms develop. For example, a Colonoscopy is preventative, (unless there are polyps that need to be removed or other problems found) then the doctor will not bill the insurance for a preventive procedure but instead bill it as a diagnostic procedure. If it’s billed as “diagnostic”, you will then be subject to pay your deductible, co-pay and/or out of pocket maximum.

What Is Diagnostic Care?

Diagnostic medical care can diagnose, monitor, or treat existing problems. This may include following up on abnormal test results to further investigate a problem or treat certain symptoms. It may also include procedures such as removing moles, skin tags or treating back pain. As in the paragraph above, removing polyps during a preventive colonoscopy now makes the procedure not just an examination, but a diagnostic procedure. The polyps could be sent to the laboratory for further analysis to determine if anything is cancerous. All diagnostic charges will involve your deductible, co-insurance, co-pay, and/or out of pocket maximum.

Why It Is Important to Know the Difference

There is considerable overlap between preventive and diagnostic care, and it can be confusing to know which category a given service falls under. In some cases, a service may be categorized as preventive for one patient and diagnostic for another. For example, a blood pressure check that is part of a routine annual checkup for someone with no history or risk factors for high blood pressure is preventive care. On the other hand, it is considered diagnostic if the individual experiences symptoms such as chest pain, severe headaches or has a history of high blood pressure already in their past or present.

Many preventive services are covered under ACA-compliant health insurance plans at 100%, meaning the individual doesn’t pay a copay or coinsurance for services. For example, if you are being seen without symptoms or for routine yearly checks, it could be billed preventive. If you are being seen with symptoms, it most likely will be billed diagnostic.

Before obtaining a test or service, it is helpful to talk to your doctor about why it was ordered. Knowing this will help you determine whether it will be preventive and fully covered or diagnostic causing you to have a cost-sharing responsibility. If you find you’ve been billed for something you thought was supposed to be preventive, find out from the billing department at your doctor’s office how they billed the insurance company.

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Finding the Right Health Insurance with Nevada Insurance Enrollment

The cheapest health insurance plan is not always the right one for your needs, and skimping on coverage for preventive and diagnostic care can end up costing a lot of money. At Nevada Insurance Enrollment, our health insurance agents specialize in helping you evaluate your health needs, expected medical expenses and budget to find the plan that is a good fit for you.

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