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It can be frustrating if you receive a bill for a healthcare service you assumed would be covered completely. Sometimes this happens because of the different billing categories your provider may use for the medical services provided during your visit. Learn more below.
Diagnostic (problem-focused) Care is the care when:
Preventive and Diagnostic Care may happen at the same visit.
Most of the time, preventative care – such as a wellness visit or a physical – does not require a co-pay. But if your healthcare provider addresses a new or chronic medical issue during a preventative visit, you may have to pay a co-pay, deductible or co-insurance for the diagnostic (problem-focused) care portion of the care you receive. We recommend you always confirm coverage with your health insurance plan.
|WHAT YOU PAY
|WELL CHILD VISIT
A 6 month-old child has a well-baby visit, including receiving vaccines.
A 40-year old man has a routine physical.
The doctor orders routine screenings, including lab tests to check cholesterol.
|Most insurance plans cover preventive care such as routine physicals or well-child visits at no cost (including vaccinations and preventive screenings).
However, there can be exceptions so you should check with your health plan to confirm.
|Preventive & Diagnostic (Problem-focused) Visits
|ROUTINE PHYSICAL WITH ADDITIONAL TESTS/SERVICES FOR A CHRONIC OR NEW CONDITION
A patient was diagnosed with high cholesterol last year. During the patient’s routine physical this year, the doctor also discusses the patient’s diet and medication, reviews possible side effects and orders lab work to monitor the condition.
|If your insurance plan covers preventive care at no cost, you will pay nothing for the routine physical portion of your visit.
However, you may have to pay something for your doctor’s assessment of a previously diagnosed condition or a new condition as those services are considered Diagnostic services.
|MEDICARE PATIENTS – ANNUAL WELLNESS VISIT WITH ADDITIONAL TESTS/SERVICES FOR A CHRONIC CONDITION
A patient has their annual Medicare wellness visit. During the visit, the doctor discusses various health risks and how to reduce them. They also discuss the patient’s diabetes and current medications.
|Medicare Part B covers a yearly “wellness” visit which includes a health history, cognitive assessment and health risk screenings.
This is not a physical exam. While the “wellness” visit portion is covered at no cost, you may have to pay something for your doctor’s assessment of any previously diagnosed conditions and any testing ordered to monitor that condition. Please note that traditional Medicare does not cover annual physicals, routine eye exams or routine hearing exams.