Managed Care Frequently Asked Questions
Preventive Care Coverage and Cost Sharing

Why did I receive a bill after my annual physical exam/wellness visit?

You may receive a bill if your provider performs a service or orders a test that isn’t preventive according to the USPSTF. Examples of when you may receive a bill include, but are not limited to:

1. A polyp is discovered during a routine colonoscopy screening
2. A cyst is discovered during a sterilization procedure
3. Cholesterol labs completed during an annual physical exam because you have a history of high cholesterol
4. A mole is removed due to its concerning appearance
5. Your provider runs a lab that is preventive after age 55, but you are younger than 55
6. Your provider describes a service or treatment as “preventive” or “preventative”, but it’s not recommended with an A or B rating by the USPSTF 

What is the difference between a routine screening test versus a diagnostic test?

Routine screening tests are for patients without symptoms. Examples include a colonoscopy screening beginning at age 45, or a mammogram beginning at age 40. Routine screenings are covered as preventive with no member cost-sharing, per the ACA.  

A diagnostic test is for patients with symptoms, or when an abnormality is found in patients without symptoms. You might receive a bill for a diagnostic test. A routine screening can become diagnostic in some situations. For example, you may schedule a routine colonoscopy screening and have no concerning symptoms to report. However, during your colonoscopy your doctor finds a polyp that is subsequently removed and sent to pathology for further testing. You may then be responsible for member cost-sharing for the removal and testing of the polyp that was found during your colonoscopy.  

Before a procedure that involves anesthesia (drugs that may make you sleepy or unconscious), you will go through a consent process. This is where a doctor or care provider explains the procedure, the risks of the procedure, and may also explain that the screening procedure could become diagnostic. If you have questions, you can ask your doctor or the person going over paperwork with you. If you don’t understand, or aren’t sure, you are always allowed to ask more questions. It is the doctor or health care provider’s job to make sure you understand what you are signing.

How do I know my appointment will be preventive and paid in full by my insurer?

You can take the following steps before your appointment:

1. Call your provider and ask them what they’ll be billing for your upcoming appointment or service.  
2. Ask your provider for their National Provider ID (NPI) to make sure they are in-network for your insurance plan.  
3. Ask which procedure codes (often called CPT codes) your provider might bill to your insurance company.
4. Call your insurer and tell them what your provider is planning to bill. You’ll receive more accurate information from your insurer if you have accurate information from your provider.
5. Remember, your insurance company can’t control or change what your provider bills. It’s important to have a good understanding of your provider’s billing practices before you receive care