Paying for a Routine Checkup

Insurers, Doctors and Patients Don't Always
See Eye to Eye on How to Define 'Preventive'

August 18, 2005

What's preventive health care?

For some patients with high health-insurance deductibles, the answer isn't so simple when it comes to who actually pays the doctor's bill.

As it has become increasingly common for the deductibles on certain health plans to stretch to $1,000 or more, many insurers offering these plans are making an exception: They'll pay for preventive care, regardless of whether you've satisfied your deductible. The idea is to keep patients from forgoing physicals, mammograms and other services that are meant to keep them healthy.

In the past few years, insurers have been adding preventive-care benefits to many types of plans, according to insurance trade-group America's Health Insurance Plans. The issue has become particularly important for high-deductible plans that can be used along with health savings accounts, tax-advantaged accounts to save and pay for medical and other expenses. Aetna Inc. in July released a list1 of "preventive" prescription drugs which, for many of its HSA plans, can be covered before patients have satisfied their deductibles.

But different insurers sometimes have different views on what constitutes preventive care. What's more, doctors don't always label services as preventive when submitting charges to insurers. And when there are gray areas, often patients are the ones who end up with the bill despite their insurance coverage.

"There is no industry-wide definition here, so each insurer has the ability really to define preventive services for themselves," says Andrew Baskin, a senior medical director at Aetna, based in Hartford, Conn.

To be sure, not all patients will get lost in the details of what's preventive. But Barbara Wilcox of Denver is one patient who has.

When she went for what she thought were routine, preventive doctor visits in March, she expected all of the charges to be paid in full even though she hadn't met her $2,200 deductible on her HSA plan through UnitedHealthcare.

To her surprise, she ended up receiving more than $300 in bills for the care. Some of the charges were for a pap smear and a lipid profile, blood tests often used to check a patient's risk for coronary-artery disease. Another was for a blood-pressure test.

Ms. Wilcox, 62 years old, says she knows that part of the idea of high-deductible plans is to encourage patients to be more careful shoppers for medical care. But right now she misses her old plan, which had simple copayments for doctor visits.

"How can I make logical decisions when I don't even know what the rules of the game are," says Ms. Wilcox, who adds that after a series of phone calls to her insurance company and doctor's office, she's made some headway toward getting at least the pap smear paid for.

The main issue seems to have been the communication between her doctors and UnitedHealthcare. When Ms. Wilcox's doctors submitted the bills for her services, they didn't indicate that the services were preventive, according to what UnitedHealthcare customer-service representatives told her.

"If they designate it appropriately, then we treat it appropriately," says Mark Lindsay, a spokesman for Minnetonka, Minn.-based UnitedHealth Group Inc.'s UnitedHealthcare. Administrators for Ms. Wilcox's doctors, meanwhile, told her the bills were submitted correctly, she says.

Regardless of who's right, this type of issue likely wouldn't surprise Rick White, chief executive of MedaPhase Inc., a consulting firm based in San Antonio that helps physician practices with billing issues. Historically, insurers have been far more willing to pay doctors to treat specific problems, and often haven't covered preventive care, Mr. White says. As a result, making clear that treatments are preventive is "literally the opposite of what most doctors' offices are accustomed to doing," he says.

There's also room for disagreement. For instance, during Ms. Wilcox's annual physical, the doctor found that she had high blood pressure and asked her to come for a follow-up check to see if the first test was an anomaly. It was that second blood-pressure test that UnitedHealthcare didn't pay for, she says. UnitedHealth says it might have considered the second test preventive -- and paid for it -- had the doctor submitted the bill that way. Aetna, meanwhile, says it normally wouldn't cover that type of bill as preventive care.

There are some government guidelines for HSAs plans, creating the limit that they pay for only certain items before patients have satisfied their deductibles. These items include periodic health evaluations, routine prenatal and well-child care, immunizations, screenings such as pap smears, and prescription drugs that are used to prevent diseases or keep them from recurring, according to the Treasury Department8.

Insurers offering HSA plans aren't required to cover preventive care upfront. Those that do may not always choose the same items to pay for, especially when it comes to services that are less widespread than physicals and mammograms. For instance, Lumenos Inc., an Alexandria, Va., health plan recently acquired by Wellpoint Inc., says it typically considers osteoporosis screenings preventive for certain women with HSAs. Kaiser Permanente, a health-maintenance organization based in Oakland, Calif., say so far it's not calling osteoporosis screenings preventive for its HSA plans.

A big issue is prescription-drug coverage. The Treasury Department's prescription-drug guidelines have created an especially "wide swath of gray," says Jay Savan, a consultant at employee-benefits consulting firm Towers Perrin. Most insurers haven't developed a list of medicines they consider preventive. Examples of some of the medicines included on Aetna's list were for blood pressure, diabetes and osteoporosis. Arthritis drugs were among those left off the list.

Though it may hard for patients to get into these sorts of details, it helps to gather as much information as possible about what your own insurer considers preventive. Many insurers post descriptions of preventive care on their Web sites and provide outlines on their summaries of their plans' benefits. It's important not to forget that many of the same rules that apply to traditional insurance plans also apply to high-deductible plans. For instance, many plans cover no more than one physical a year. If the plan summary doesn't go into a lot of detail, you may want to call your insurer and ask if the services you expect to receive would be considered preventive.

One helpful technique is to bring a copy of your insurer's plan summary or preventive-care descriptions to the doctor's office. Explain to both the doctor and receptionist that you have coverage for preventive care and would like the office to make clear to your insurer what's actually routine, says Mr. White of MedaPhase.

In some cases, you may be able to convince your insurer to count something as preventive for you, even if it wouldn't be categorized that way for other patients. For instance, Lumenos calls colonoscopies preventive for people aged 50 and over. But if a patient had a relative who had colon cancer early in life, the patient would be considered "high risk" and could get coverage for a preventive colonoscopy before 50, says Michael Parkinson, Lumenos' chief health and medical officer.

As for Ms. Wilcox, in the months since her doctors' appointments, she says she's sometimes debated whether to keep pursuing the issue or "just pay the bills and forget about it."