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Preventive care is supposed to be covered by insurance plans – so what’s the story behind those surprise bills?

By James D. Schutzer, Vice President, JDM Benefits

The world of healthcare can be full of surprises, from the cost and course of treatments to the side effects of medicine.

One of the surprises most frequently discussed are unexpected bills – the invoices that arrive in the mail for a visit you thought your insurance covered. These charges can be aggravating. Indeed, a recent Kaiser Health poll revealed that, when it comes to expenses, Americans rank unexpected medical bills as their chief worry – even above prescription drugs, gasoline and their mortgage.

Kaiser elaborates: “Four in 10 insured adults ages 18-64 say there has been a time in the past 12 months when they received an unexpected medical bill, and one in 10 say they received a ‘surprise’ medical bill from an out-of-network provider in the past year.”

These surprise bills can be especially aggravating if they’re related to preventive care – a service many insurance plans say they cover.

So, what’s the story behind surprise charges stemming from preventive care?

First, let’s define “preventive care.” Preventive care involves proactive healthcare services, such as screenings and immunizations, that prevent illness or disease rather treat existing problems. Insurance carriers list cholesterol tests, mammograms and prostate exams as key examples of preventive care.

According to the Affordable Care Act (ACA), preventive care involves a wide range of services – from screenings for obesity and high blood pressure, to ones for colorectal cancer for those ages 50+, as well as screenings for genetic counseling for the BRCA breast cancer gene, and more. Regular preventive care visits and health screenings may help to identify potential health risks for early diagnosis and treatment, helping you live a healthier life.

It goes without saying that preventive care is prudent for individuals. Preventive care “increases lifespan,” increases the “ability to be active and take part in life” and can “prevent large medical bills or bankruptcy,” reports USA Today.

Insurance carriers encourage their members to seek preventive care, as the relatively modest expense can prevent expensive treatments two, five, or 10 years down the line.

In the U.S., however, preventive care is an underutilized resource. “Nationally, Americans use preventive services at about half the recommended rate,” according to the Centers for Disease Control and Prevention.

Why? Many Americans are still confused with their health insurance plans, especially when deductibles, co-insurance, or copayments associated with preventive care may apply. This brings us back to those surprise charges.

Many insurance plans cover basic preventive care measures at 100-percent, without charging a deductible, co-insurance, or copayment. However, this may not include additional measures that might be required if something is found. For example: age-appropriate colonoscopies are considered preventive and are covered at 100-percent but, if the preventive service results in a diagnostic procedure, the patient may incur deductibles, co-insurance, or copayments.

Further, your preventive care may be free – but that’s only the case in-network. If the doctor down the block doesn’t accept your insurance, then you’ll have to pay out-of-pocket for that check-up or vaccine. Seeing out-of-network physicians for preventive care is a common mistake – so much so that the ACA website has a large disclaimer at the top of its preventive care page, “IMPORTANT: These services are free only when delivered by a doctor or other provider in your plan’s network.”

A third problem? Even though you might consider a service preventive, your insurance plan may not.

So, how can you best avoid these surprise charges? As Sy Syms said, “An educated consumer is [the] best customer.”

For individuals, start by getting familiar with your healthcare plan. Learn what is and isn’t covered when it comes to preventive care. If there’s any ambiguity, call your provider and speak with your doctor early and often. Also ensure you’re seeing a doctor in your network.

If you’re an employer, it’s important to pass these tactics along to employees. For this reason and many others, you can work with JDM Benefits. We help employers – from those in the legal, tech and nonprofit industries, to others in the media and financial services industries, and elsewhere – navigate the complex realm of healthcare. JDM can provide the expertise and technology you need to ensure your HR and insurance efforts aren’t caught by surprise.

James D. Schutzer