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Practice News | 11/26/2019

Avoiding Unexpected Medical Bills

By  Atrius Health
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:
  • Depression screening - At a time when many people of all ages and at different stages of life may suffer from depression, it is becoming more routine to offer patients a depression screening test at an annual physical exam, wellness visit, or in association with pregnancy. Depression screening may not be covered fully or at all.
  • Lab testing - Lab tests may be considered diagnostic and have associated out of pocket costs when the tests are ordered because of either your medical history or a current condition that is being investigated. For example, if you have a history of diabetes, a hemoglobin A1C test will be considered diagnostic because the test is helping the clinician to assess the level of your disease.
  • Colonoscopy - Most health plans will fully cover a routine screening colonoscopy once every ten years. If a polyp is found during your screening procedure (which is the case about 60% of the time), then you may incur an expense associated with the lab/pathology tests that are run to assess the polyp. If you have had polyps previously, have certain other gastro-intestinal issues, or if it has been less than 10 years since your last colonoscopy, the test is likely to be considered diagnostic, potentially leading to an out-of-pocket expense.
  • Mammograms and additional diagnostic imaging - Most insurance plans cover screening mammography care that occurs within certain guidelines related to age and past medical history. If, however, you receive a mammogram that was ordered because you have symptoms such as a lump, pain, discharge, or prior history of breast cancer, or if the mammogram is a follow-up to monitoring a specific condition or biopsy, the mammogram test is likely to be considered to be diagnostic and may lead to out-of-pocket costs. Similarly, if the radiologist determines after a routine mammogram that additional images and/or an ultrasound are necessary to confirm findings, these tests would be considered diagnostic and could result in additional charges.
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.
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About The Author

Atrius Health

Atrius Health, an innovative healthcare leader, delivers an effective system of connected care for adult and pediatric patients at more than 30 medical practice locations in eastern Massachusetts. By establishing a solid foundation of shared decision making, understanding and trust with each of its patients, Atrius Health enhances their health and enriches their lives.

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