Know what’s covered… and what’s not
Have you ever received a statement following a preventative visit and thought, “Shouldn’t this be covered at 100%?” If so, you’re not alone. Many health insurance plans follow the guidelines of the U.S. Preventive Services Task Force (USPSTF). And although sharing nearly the same acronym as our post office, this group does not deliver mail. Due to the ACA mandate to provide preventive services with no patient cost, we now rely on the USPSTF to determine if healthcare services are recommended as “A” or “B” graded preventive services, which most plans pay at 100%.
So, what’s the problem?
Well, if your doctor orders tests, or provides services outside of this list, your health plan will likely apply patient responsibility in the form of copay or deductible. Whether you agree with your doctor’s order or the “Task Force” recommendation, your plan document is the trump card when confirming who pays for these services.
So, what should you do?
Step 1: Know the tests your doctor plans to order for your annual check-up.
Step 2: Ask your doctor if the “Preventive Task Force recommends the test.” If yes, your health plan will likely pay for it.
If the answer is no, ask what condition or risk factor leads the doctor to believe the test is necessary. Then ask how much it costs.
If your copay covers all services at an office visit, ask your provider to perform the test in-house, and bill as a separate office visit. (BCBSM Community Blue and some self-funded plans have these “all-in” copays).
If your copay only covers the office visit charges, or you have an HSA, your deductible will likely apply for these services (BCBSM Simply Blue, BCN HMO, most Priority plans, and most self-funded plans have these “restrictive” copays).
If the blood draw or test is performed before the office visit (usually the case) and it is not an “A/B recommended” test, you’ll either pay a lab copay or pay for the entire service (as deductible applies). Click here to know what you should pay for lab tests.
Step 3: Print this list, and bring it to your first visit. Most physicians have no idea how the finance side of their practice works. The list of “A/B” services is in alphabetical order, so your doctor or lab tech can quickly identify if your health plan covers the service (or test) at 100%.
Step 4: Lastly, if you don’t agree with a bill: CALL! High volume services, like office visits, are mis-billed quite often. So, call your doctor’s office before paying the bill. Or, use your healthcare concierge (if your employer provides).
As always, we welcome your comments or questions. Feel free to ask below. Or, if you’d like our team to symplify your member’s experience, give us a call 844.447.9675.
Author: Wes Spencer
Co-Founder, Sympl Benefits
