Michelle Waldow, Licensed Benefits Consultant with The Health Insurance Store/Medicare Plan Options Answers Our Ask the Expert Question

Michelle WaldowQ:  I seem to be confused about the Preventive Services offered on my health insurance plan. My booklet shows a list of services that are covered with no copay or coinsurance for the patient, but sometimes I still get a bill from my doctor or another type of health care provider for items on the list.  I don’t understand why I would receive a bill. Should there be a charge for preventive services?

A:  Good question! When I was a claims adjuster working to solve errors on billing, preventive service claims often had to be reviewed to verify that they were billed correctly.  Basically, the bill should be based on the reason you are seeing your doctor. The visit may have a “routine” (preventive) or “medical “(diagnostic) code affiliated with the service. If you are there to have a general checkup and verify that all is well, the visit will most likely be preventive.  (It is a good idea to verify with the office staff when you sign in that you are there for a wellness visit). On the other hand, if you have a specific complaint or diagnosis, such as asthma or gall stones, your visit is most likely going to be for a medical reason and diagnostic in nature.

But sometimes your visit is not quite that simple. While you are at the office for your annual wellness visit, the doctor may decide you need a lab test to verify that all is well. Or due to your age and or gender, it may be time for some screenings for early detection of problems. The physician hands you the prescription to have the test, you go to the lab or diagnostic testing center for the screening and think nothing further of it. The results come back and you are in great shape. Excellent news! Until you get the bill from the lab. Bill? You thought preventative services were covered at 100%! A few things could have gone wrong. Did you verify that location of your service would be covered by your insurance company? And keep in mind, not all preventive services are covered at 100%.  It could also be that something about the request for a preventive test may have indicated that you required a medical test. The culprit for the problem is most likely the coding on the bill. It sounds crazy, but a lot of the same tests can be preventive or medical in nature.

Why would that matter? Because the information on that request will determine how much you will be expected to pay for the service. Preventive services are intended to prevent illness or detect problems before you notice any symptoms. The goal is to catch problems early and keep people healthy, which is a cost savings.  Preventive service codes may indicate that no payment is owed by the patient. Diagnostic medical care involves treating or diagnosing existing problems and symptoms. Diagnostic billing codes will most likely indicate a payment is owed by the patient. Therefore, you may receive a bill if the codes indicate a medical service.

So, what can you do if you think your bill was a mistake? Well, most importantly don’t make a payment until you verify what you actually owe. The place to start is with your insurance carrier. Have the bill from the provider as well as the explanation of benefits from the insurance company with you when you call the member services number on the back of your insurance card. Request the claims department and let the representative know that you would like them to review the claim. It could be an error on their end, possibly in the computer program that processes claims. If so, they will adjust the claim. It is important to note that an insurance company can only adjust their internal error. They are never allowed to make changes to the original claim that was sent from a doctor or medical provider. If the issue is something that was sent on the original claim, you will then need to contact the office where you had the service. Ask for the medical biller or person that works with insurance. They will review your chart to see if they entered the information on your bill correctly. (Sometimes you may need to speak with multiple people to get someone that can help.)  If there is an error with the claim, they should resubmit the claim. If the billing was correct, the office staff will explain the reasoning for the billing and they should answer any questions that you have.

This process can be tedious but don’t give up! It can take work but if there is an error on the bill it may be corrected and the patient share is put back to the correct amount listed in your summary of benefits. Stay Well!

The information provided is not intended to be medical in nature. Please refer to your health care provider or your insurance company for any health care related questions or concerns.


Michelle Waldow has been working in the health insurance industry for the past ten years. Her experience includes claims administration, patient advocacy, medical policy review and ERISA appeals work. Michelle is currently providing Benefits Consulting services with The Health Insurance Store’s Medicare Plan Options office, as well LTC Advisors, both located at One Senior Place in Altamonte Springs. If you have questions or need more information call Michelle at 407-963-2332.