Doctor and clients

What is the difference between preventive and diagnostic care?

To avoid surprise charges, it is also important to understand that “preventive care” is care that is provided to help prevent future illness when you don’t have any history, current symptoms or other related health concerns.  Preventive care may take into account your age, family history and other risk factors to determine the proper screening studies that are necessary for you to have.

However, when you are seen for a known or long-term health concern (e.g. diabetes, high blood pressure, etc.), those tests and services are likely to become “diagnostic” and not preventive because the provider  is trying to diagnose you based on signs or symptoms you may be experiencing. Diagnostic services are covered benefits,  but they are not covered without some cost share from you. They will apply to your benefits (copays, deductibles and coinsurance).

 

How to Avoid Surprise Charges

    • Know what services are on the no cost share preventive care list provided to members by CGHC. Services you may think of as routine or preventive might not fall under the definition of “no- cost-share.” You can also call us at 877.514.2442 to better understand your benefits.
    • A service that qualifies for no-cost-share preventive care must be provided by an in-network health care provider. If you are scheduling an appointment to receive no-cost-share immunizations or screenings, be aware of any other services  recommended to you during your visit, and remind them that you are only interested in receiving the no-cost preventive services.
    • Be mindful of raising health concerns during a visit that is meant to be preventive in nature. If you raise health concerns that require your provider to order additional tests above and beyond age-appropriate preventive or screening tests, you will likely be responsible for the charges that are related to working up those concerns. If the provider bills the visit as diagnostic, or if diagnostic studies result from your visit, we must process the claim accordingly (and it will generally come at some cost to you). You will have to decide if talking about your health concern is worth the possibility of being billed for non-preventive services.
    • When scheduling preventive or screening tests like colonoscopies or mammograms, for example, it is especially important to understand if the provider considers it preventive or diagnostic. Many people are surprised when colonoscopies or mammograms apply to their deductibles because they come at a higher cost than other preventive  For example, a mammogram performed to follow up on a breast lump would likely be considered diagnostic rather than screening.  Likewise, a colonoscopy performed for blood in the stool would be billed as a diagnostic, not screening, study. Generally, if these studies are designated as screening studies, there are specific indications, screening intervals, and age ranges at which such preventive studies may be performed at no cost to you.

 

Ask questions if your provider recommends additional testing and treatment during your preventive visit. If the tests don’t meet the criteria for no-cost-share preventive screening, you’ll need to pursue those recommendations with the knowledge that there will likely be some cost-sharing responsibilities. Ask questions and engage in shared decision making before your provider orders a non-screening test.   If you are in doubt, and your concerns are not urgent, it is reasonable to make an additional appointment with your provider to specifically discuss problem-oriented issues.

 

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