Preventive Care Services vs. Specialist Care

An interesting question crossed my desk regarding the use of preventive health care services when specialists are involved. The patient specifically asked about coverage available for a skin cancer screening performed by a dermatologist that the patient considered to be preventive health care based on an experience with a previous health insurance carrier. Having personally felt confused between what services are covered and what are not when it comes to preventive care, I contacted the ASRS Health Care Administrator, UnitedHealthcare (UHC), to research the request. I learned the following tips to share with UHC members and patients who may be experiencing difficulty defining the line between preventive care and specialist- or diagnostic- care.

What is preventive medical care?

Preventive medical care often includes services such as immunizations, lab tests, and other screenings in order to detect health problems before symptoms develop.

What is diagnostic care?

Specialists often perform diagnostic medical care, meaning the physician is treating or diagnosing an existing health problem based on prior test results or the onset of symptoms the patient already discussed with their physician or provider.

From the perspective of the patient, it is important to remember that once a specialist is involved, it means the health issue is already known, and will likely be considered diagnostic.

What determines cost for service?

The way the service is coded by the health care provider. Insurance codes are used to identify a procedure by health plans and communicate the costs involved for the service provided. This code confirms what amount is owed to the physician or provider for that service. These services can be found on the Explanation of Benefits you receive from UHC when, as a patient, you are billed for your portion of the cost for the medical services. However, requesting this code from your medical provider in advance will allow you, to contact your insurance company to confirm coverage for the recommended service. Using the diagnosis code can also assist you with estimating out-of-pocket costs for the recommended service by going online to use the UHC treatment cost estimator on myhce.com. In the event of a complex procedure or one requiring authorization, talk to your medical provider about submitting a pre-treatment estimate.

Preventive services are coded a certain way to indicate to the insurance company the service was for preventive care. Preventive services are identified on the A & B Recommendations of the U.S. Preventive Services Task Force as part of the Affordable Care Act.

It’s important to note that many of these preventive screenings are often part of an annual wellness physical, and are therefore coded accordingly, meaning these are services that are covered at 100%.

In order for a claim to be considered covered at 100% by UnitedHealthcare, it must be listed on the A & B Recommendations of the U.S. Preventive Services Task Force, and submitted with preventive coding (meaning not diagnostic). If a patient chooses to have services rendered by a specialist, like in the case of our patient and the dermatologist, that claim will be submitted as a diagnostic office visit and UHC would process that claim with the applicable specialist office visit copay.

What if I don’t want to pay the copay?

The patient could ask their primary care physician about the cancer screening, or other preventive services available, and have the preventive service performed as part of an annual wellness physical.

Visit the U.S. Preventive Services Task Force webpage for a complete list of services considered preventive care. UnitedHealthcare includes a list of preventive services on their website as well.

What if I need a specialist?

How will I know which specialist to choose? How do I find out the cost estimate? While health maintenance would be much simpler if our primary care physician could handle everything, there are times when we need to call a specialist. Selecting an in-network specialist can seem like a complicated mess, but don’t let that scare you. For UHC members who have a tiered benefit plan, UnitedHealthcare makes finding a specialist and an expected cost estimate as simple as logging on to their website.

UnitedHealthcare has a program which identifies UHC Tier 1 providers in the patient’s network. This helps patients identify providers with lower costs. This information can be viewed after the patient logs into their myUHC account.

Why are the specialists tiered?

The program evaluates physicians where there are quality measures available to evaluate their performance.  Not every type of specialist will have these standards available, and therefore, will not have an evaluation performed. Dermatologists are an example of a specialist without an available evaluation. For other specialties, like oncology, supplementation information necessary to evaluate performance, such as the stage of cancer, is not available from claims data and the specialty is not able to be evaluated by the program. This means, non-evaluated specialty providers could have a higher cost associated with their services.

Will this ever change?

UHC is continuing to address these issues through their work with national specialty societies to develop measures and to obtain data from supplemental sources, such as national registries, in order to evaluate all specialties.  For now, any patient who is a UHC member that has a tiered benefit plan and seeks the services of a non-evaluated specialty provider will experience the standard or higher copayment.

Points to Remember:

When unsure if a service will be covered at 100%, check with your primary care physician to confirm the service is part of the annual wellness physical, and refer to the list of A & B Recommendations of the U.S. Preventive Services Task Force. As a patient, knowing the intent is to have lower out-of-pocket costs for preventive care, and knowing what preventive care is doing to support better health can dramatically increase the value of diligently scheduling those annual wellness physicals.

Remember it is okay to ask your health care provider what the service or test is for and how it will be coded when sent to the insurance company. If you still have questions about the coverage and costs of a particular service you can call UHC at the number listed on your UHC ID card, and discuss the service and coverage based on this code.

When a specialist is needed, log in to your myuhc.com account ahead of time and search for the providers in your network. This will allow you to filter and narrow your search to meet your needs and anticipate costs so you will be more prepared for your visit. Remember that specialists are coded as diagnostic- not preventive- so you will be expected to pay the applicable copay for your benefit plan. Finally, bear in mind that your myuhc.com account will help guide you to the providers in your network, but researching your in-network options, reading physician reviews, and asking for referrals may also be necessary to help you feel confident in the final steps of selecting your specialist.

by Courtney Micheau,  Member Services 

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