One of the most common complaints to health care providers and health plans comes when a patient receives a bill for a service that the patient assumed would be covered completely. In many cases, this is because health plans typically cover preventive care in total, but may not completely cover diagnostic care. And if a clinician provides both preventive and diagnostic care during the same visit or procedure, you may have to pay some portion (such as a copayment, deductible, or co-insurance) for the diagnostic services.
Preventive care includes services such as checkups, screening tests, and immunizations—care that you get when you’re symptom-free and have no reason to believe you might be sick.
Diagnostic Care is what you get when you have symptoms of an illness or injury or are being followed for a chronic condition, and your doctor wants to diagnose or monitor the condition. This care may include an office visit, tests, or treatment(s).
In most cases, you don’t pay anything for preventive care. However, sometimes preventive care is only covered at certain intervals (e.g. colonoscopy every 10 years), so you may have to pay if you seek that care more often than what your health plan covers.
Diagnostic care results in an out-of-pocket expense more frequently than does preventive care. Furthermore, when both preventive and diagnostic are provided at the same visit, you will likely have to pay a copayment, deductible, or co-insurance for the diagnostic services. We recommend that you always confirm with your health plan what your coverage is for both preventive and diagnostic care.
The most common unexpected bills occur for:
Knowing What to Expect
Coverage varies greatly among different health plan products, so we recommend that you call your health plan to understand your benefits. Ask questions about lab tests and screening tests such as mammograms and colonoscopy, and how often your health plan will cover these services. Ask if you will have any out-of-pocket expenses for imaging, office visits and lab tests that are diagnostic in nature. Understanding your benefits will help you to be better prepared when a bill arrives.
If your health plan indicates that there are out-of-pocket costs for diagnostic tests and you want to know how much you should expect to pay, we can provide you with a pricing estimate for services performed at our sites if you call our Atrius Health Patient Billing Call Center (1-800-898-7980) with your health plan information.