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If Medicare covers preventive care services at 100%, why was I sent a bill after my preventive care visit?

The short answer is the bill may very well be valid based on the results of certain preventive care services…….  Here’s why.

Medicare does cover many preventive care services at no cost to the enrollee regardless of whether you are covered under Original Medicare and a Supplement Plan (aka Option 1) or you’re covered by a Medicare Advantage Plan (aka Option 2).

So what exactly is preventive care?

A service is considered preventive care if you have no prior symptoms or disease.  Preventive care services are designed to prevent illness, detect medical conditions, and generally keep you healthy.

Examples of preventive care services covered by Medicare

  • Annual “wellness” visit
  • Breast cancer screening (mammogram)
  • Cardiovascular screening
  • Colorectal cancer screenings (colonoscopy, fecal occult blood test, flexible sigmoidoscopy)
  • Diabetes prevention program
  • Hepatitis C Screening
  • HIV screening
  • Medical nutrition therapy services
  • Prostate cancer screenings (PSA)
  • Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
  • “Welcome to Medicare” preventive visit (one-time)
  • Abdominal aortic aneurysm screening
  • Bone mass measurement
  • Cardiovascular disease (behavioral therapy)
  • Cervical and vaginal cancer screening
  • Depression screening
  • Diabetes screenings and monitoring
  • High Intensity Behavioral Counseling
  • Lung cancer screenings
  • Obesity screenings and counseling
  • Sexually transmitted infections screenings and counseling
  • Vaccines, including flu, hepatitis B, pneumococcal, and COVID-19 shots

Preventive care is different from diagnostic care.

It’s worth noting the differences so you are not surprised on those occasions where, depending on your coverage, a copayment, coinsurance, or a contribution toward a deductible may be required.

A service is considered diagnostic if it addresses symptoms or conditions that you already have.  It diagnoses problems, treats a symptom(s) or specific condition(s), and may result from follow-up on abnormal tests results.

How a service is classified (preventive or diagnostic) can impact your out-of-pocket costs.  You may owe a co-pay, co-insurance, or all or part of a deductible if a service is diagnostic.

Preventive care is usually no cost regardless of the type of Medicare coverage you have.

So, coming back to the original question…. The answer is you could be charged for diagnostic care during a preventive visit, if your doctor finds any problems in the course of the preventive care service.

This month’s Medicare Minute (courtesy of the Medicare Rights Center) provided some good examples worth sharing.

What do you think, Preventive or Diagnostic?

Your doctor says you should have a glaucoma screening.  You aren’t experiencing any symptoms, but your diabetes puts you at higher risk for glaucoma.  Preventive or Diagnostic?

  • PREVENTIVE. This doesn’t treat any symptoms/problems and is meant to keep you healthy and detect a condition.

While playing golf your club hit a tree root and you broke your wrist.  You are fit for a cast and then prescribed physical therapy to restore range of motion.  Preventive or Diagnostic?

  • DIAGNOSTIC. The treatment is for an injury of a condition you already are experiencing.

You receive your annual flu shot.

  • PREVENTIVE. This is meant to prevent you from getting very sick with the flu and does not treat flu symptoms.

In a recent colonoscopy, which is administered at regularly scheduled intervals because of your family history, your doctor finds multiple polyps and has to remove them.  Preventive or Diagnostic?

  • BOTH PREVENTIVE AND DIAGNOSTIC . The colonoscopy is preventive, as you don’t have any symptoms of colon cancer.  The removal of polyps is diagnostic.  It treats the problem the doctor discovered during the colonoscopy.  You may be billed for the diagnostic services performed to address what’s discovered during the colonoscopy.

Further Discussion

If there are specific topics you’d like us to address in future issues, please drop Tom a line at tbarrett@bbginc.net with your suggestions.