The Press Newspaper

Toledo, Ohio & Lake Erie

The Press Newspaper

The Press Newspaper


With the ever-changing nature of our healthcare system, many things about our individual insurance coverage exist, which many of us may not be aware of, or even know they exist in the first place. 

It would take more than just this article to cover all the intricacies, changes, twists and nuances of all the different types of health care coverage, so I’ll touch on just one topic for the time being – “preventative screenings.”

So what is “preventative care?” Under the Affordable Care Act, if you have a new health insurance plan or insurance policy beginning on or after Sept. 23, a series of preventive services must be covered without your having to pay a co-payment or co-insurance or meet your deductible. This applies only when these services are delivered by a network provider.

Many health care services are determined to be preventative, which means you may not have to pay for the qualified procedure, test or screening. Many of these services are age-driven. For example, individuals 50 years old and over would qualify for preventative colo-rectal screenings typically in the form of a colonoscopy. It sounds pretty straightforward, doesn’t it? Well, maybe, maybe not.

Let’s take a “hypothetical” case and see where this preventative care concept can go awry.

An over-50-year-old gentleman is advised by his family physician that it is time for his preventative colonoscopy screening, either because it is his first, or because it has been 10 years since his last procedure. An appointment is scheduled with a provider and he is readied for the testing. When the appointment was made, the office personnel advised him, “you realize, sir, that if anything besides the colonoscopy is performed at that time, you may have financial liability.” Now that’s confusing. He was under the impression that this was “preventative” and would require no “out-of-pocket” expense on his part.

He has his colonoscopy, and was informed that a “polyp” was found and biopsied. After being evaluated by a pathology lab, the results were negative. That said, he still believed this was preventative and should be covered under the listing of covered services – that is, until he receives the bill. What was supposed to be a preventative service has now become a $200-plus expense.

Inquiries to his insurance provider reveal that it appeared that the procedure was ”coded” improperly by the performing provider’s billing staff, apparently by the lack of use of a specific “modifier” which would have paid the provider a little more than merely a preventative procedure, but would also have kept the procedure “preventative” in nature.

An accidental billing error…maybe.

Now, there are some services out there which may fall under the “preventative” heading and are not being covered, such as flu and shingles shots and this may well be due to plan coverage, so it’s imperative to check before undergoing preventative care services. It really is up to all of us to be more educated. We simply cannot rely on others to be correct all the time.

This article isn’t meant to be an indictment towards any health care provider, rather it is meant to be a wakeup call to all of us that we must become more aware, educated and in tune with our insurance coverage details, as well as pay better attention to our health care statements and bills and to question anything that doesn’t look right.

Sure, billing errors definitely do occur, as do coding errors, but if you don’t have the awareness to make sure your bill reflects your obligations or lack thereof, you may be shelling out money unnecessarily, and the cost can be quite high.

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