Preventive visits on high deductible plans?
March 24, 2015 9:42 AM   Subscribe

I am using my high deductible health insurance for the first time. "Preventive" services are completely free. Help me understand how to stay within preventive services.

(Specifics: BlueCross BlueShield of Illinois Blue Choice Bronze PPO 006)

So I have one of those $6000 deductible catastrophic health insurance plans. Certain kinds of preventative services are completely free though (minus the premium, of course). The problem is, no one can tell me what those preventative services are or how to make sure that those services are billed correctly. I'd like to get this right on the first try.

I tossed my booklet when I got it, because I assumed all the information would be online, which it's not. I'm getting my booklet re-sent. That's step one.

But, I called the number on the back of my card, too, and they could only speak in vague generalities even though they presumably were looking right at my policy.

Further, I talked to at least the receptionist at my doctor's office, and she could also only speak in vague generalities and didn't offer any suggestions for getting my questions answered.

So, here is my question:

I want a routine physical and routine STD testing. How can I be reasonably confident that the doctor doesn't do anything that I'd actually have to pay for? If something is going to cost me money, how can I know that ahead of time, so I can decide whether I would like to proceed?

Googling didn't help much, except to maybe make sure that the billing code says "preventive" somewhere in it, before consenting to anything.

Concrete answers, or suggestions on how to be more effective in getting these answers, or an advisement to just give up and eat whatever charges I get would greatly appreciated.
posted by zeek321 to Health & Fitness (12 answers total) 3 users marked this as a favorite
Response by poster: (I know the absolute basics, like staying in-network.)
posted by zeek321 at 9:47 AM on March 24, 2015

Having the actual text of the policy should clear up your question, I'd think, but I think this is also related to the specific types of care that the Affordable Care Act covers as preventative--that list is here but also somewhat general.

The receptionist probably won't know, but you ask to talk to someone in billing--and give them specific codes to look up--they might be able to check ahead of time. I've done this before, I called and asked for someone in billing, gave them my policy number, the billing codes, and they were able to tell me what was covered. Worth a try.
posted by epanalepsis at 9:52 AM on March 24, 2015 [1 favorite]

Your health insurance company should have a website where they will tell you exactly what is and is not covered. Without knowing your plan there is no way to answer this question any more specifically than that. Health insurance companies do not like to "pre-approve" that they will pay for things and so this may have been why the person on the phone was squirrely. However, this is outlined somewhere in your plan, likely in the document you tossed out. Just make an appointment with a doctor for a check-up, check with what ACA covers, and be prepared to wrestle with people if they give you a hard time about things. The doctor's visit should be covered, extra tests may or may not be and normal ones you'd get (STD, Cholesterol, maybe other blood tests) should be specifically asked about. You can always call your insurance company from the doctor's office if you are unclear on something.
posted by jessamyn at 9:56 AM on March 24, 2015

Best answer: You can ask to be scheduled for a routine visit so they note it on the schedule. You can ask the doctor's office about what specific labwork they're ordering, and make sure it's being sent somewhere in-network. You can work with the billing contact/office afterwards if the visit wasn't coded to include that the visit was routine (I think it's a V70 code that has to be included with the diagnosis codes, they should be able to resubmit a corrected claim if they don't get it right the first time).

Here's where the wildcard comes in: the doctor doesn't know what you will need until he meets with you. That's why nobody can give you solid answers now; for all we know, the doctor will take one look at you and know you show signs of some disease that falls outside that preventive list. And jessamyn is right, insurance companies can be ultra squirrely about coverage; they can say they'll cover something theoretically that they actually won't cover once they take the whole picture of a patient's situation into account (like, in theory they cover a preventive visit, but if your doctor also finds out you have diabetes and asthma and cancer at that appointment, it probably doesn't matter if the doctor includes the V70 code on the claim). Assuming you really are generally healthy, you're probably not going to run into significant problems assuming the doctor's office knows what they're doing. If you call the billing office and they can't seem to wrap their minds around your basic questions, I would ask to speak to a manager, and if that's not satisfying, I might try to find another practice.
posted by ThePinkSuperhero at 10:04 AM on March 24, 2015 [3 favorites]

In case it helps, here is the Schedule of Benefits for your plan.

Generally speaking, in insurance terms, "preventive visit" means "well visit" - which means your yearly/routine physical with your selected, in-network primary care provider, which you have when you are not sick or injured. (You may need to select your primary care provider officially, either by phone or on the insurance company's web site.)

Most insurers pay for a physical either every year, or on a set schedule that depends on your age and health. An additional off-schedule physical, while you might still think it's preventive, would likely result in charges for you.

If you're a grown-up and you tell your doctor at your physical that you're sexually active, they will do all the routine STD screenings.
posted by kythuen at 10:29 AM on March 24, 2015 [1 favorite]

Seconding epanalepsis. In my experience talking to staff at medical offices, none of them ever know the prices and policies except the billing staff. If this cost is fairly significant given your financial situation, tell them that to give them an extra little push to go look it up. If you still can't get an answer and can't afford the risk, try Planned Parenthood for the STD part. I think a full panel is only about $100-150 and there's a sliding scale based on income.

And I am not your health insurance rep, but I had a BlueCross HDHP (but not as high as yours), and my routine physical was covered with all lab tests that the doctor ordered as needed.
posted by bread-eater at 10:31 AM on March 24, 2015

Your physical should be covered. Based on my past experience, your STD screening will probably not be part of the preventative care and you'll end up paying for some lab work. It's worth it though. It may be the case that it is cheaper to go to a clinic to get the STD screening rather than your primary care doctor.
posted by jeffamaphone at 10:33 AM on March 24, 2015 [1 favorite]

I don't know your insurance policy and can make no guarantees regarding what exactly they cover, but I can tell you that STD testing is unlikely to be included in the free coverage - it's not preventative, it's diagnostic.

Preventative means preventing you from getting a disease, not diagnosing something you already have. So if you get any testing to try to diagnose a disease that you might have (based on symptoms, physical exam, or whatever), that's not going to be covered under a 'preventative' category. A routine physical where you have no active health issue should be considered preventative for the same reason.

Things like cholesterol testing, Pap/pelvic exams, immunizations, blood pressure checks, counseling about health issues, colonoscopies - all these things can be considered preventative because they are done with an aim to prevent a disease (heart disease, cancer, stroke/kidney disease, diabetes, the flu, etc).

I'd like to second jeffmaphone's advice that going through a clinic for the STD testing may be the cheapest way to get it done - that is probably very true.
posted by treehorn+bunny at 3:53 PM on March 24, 2015 [1 favorite]

Actually the list that epanalepsis posted seems likely very relevant to me as well.
posted by treehorn+bunny at 3:56 PM on March 24, 2015

If it is a small office or a doctor you've been seeing for awhile, you could always try asking him if he would be willing to bill your insurance company specifically for something he knows will be treated as preventative care even if he did something else too. I know some places are willing to throw in a few things for free and just bill the insurance for the visit. I'm not sure how risky or not risky this advice is. I don't think it's insurance fraud or anything...only the doctor loses money he is due. I say this because my chiropractor does this for me. I'm supposed to pay him an extra copay on top of what the insurance covers, but he just takes what the insurance covers and foregoes the copay. Maybe he shouldn't do that. I really don't know.
posted by kbennett289 at 5:31 PM on March 24, 2015

The ACA lists preventative services that must be covered here.
posted by SLC Mom at 7:16 PM on March 24, 2015

I think you are right to be concerned. Several years ago (this was before ACA), I went for my free preventive visit. In addition to whatever the regular blood tests are, I asked for a Vitamin D test and a thyroid test, just to be sure everything was in order.

Nope. Not covered. Never mind that the home page for the insurance company had a huge banner ad "Ask Your Doctor to check your Vitamin D!!!" all over it. Nope. Nope. Nope. The insurance company considered those tests to be diagnostic, only to be ordered when a patient has symptoms that warrant the test. It cost me over $600.

I can't remember if it was BCBS or UHC at that time, but I suspect both are the same way. Either wait for your booklet, or follow the ACA guidelines that others have linked above.
posted by CathyG at 1:37 PM on March 25, 2015

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