latimes.com/business/la-fi-healthcare-watch-20130818,0,3875866.story
Is your healthcare considered preventive?
The new healthcare law requires insurers to cover all preventive care. But
the definition is far from straightforward.
By Lisa Zamosky
8:02 PM PDT, August 16, 2013 - Los Angeles Times
When David Brutman received a $3,000 bill for his wife's colonoscopy, he was
angry and confused. He thought the cost would all be covered because under the
Affordable Care Act most insurers must cover the full cost of preventive care
such as check-ups, vaccinations and screenings.
It seemed straightforward enough, yet Brutman, a 41-year-old Silicon Valley
entrepreneur, learned the hard way that the lines are easily blurred when it
comes to determining whether services are considered preventive care or
treatments that require payment.
"A lot of consumers don't know what's required, and a lot of doctors and
pharmacists don't know what's required. Even insurance companies are working
their way through a lot of it," said Judy Waxman, vice president of health and
reproductive rights with the National Women's Law Center in Washington.
To avoid surprise costs, learn what is free and what is not and then take the
time to think through the nature of your doctor visit, experts say. And if
you've been billed incorrectly, there are steps you can take to correct the
situation.
•Know the law: The Affordable Care Act requires most
insurers to cover the full cost of many preventive services with no co-payments
or other charges.
That means vaccinations, cancer and other health screenings, annual
well-visits, breast pumps and all FDA-approved contraceptives in most cases are
available free of charge. The government features a list of preventive health
services on its website, Healthcare.gov
that should be cost-free.
Not everyone is eligible, however. Exempt are health plans that were in place
when the law took effect on March 23, 2010. Always check.
•Understand the guidelines. The U.S. Preventive Services
Task Force, a panel of primary care experts, sets specific guidelines that
determine which medical services are considered preventive.
The key to full insurance coverage, however, lies in the details of the task
force's recommendations. For example, although colonoscopies are a recommended
preventive test, the guidelines state that it's for people 50 and older when
recommended by a physician.
In Brutman's case, his wife, who is 41, took the test at her doctor's
recommendation upon review of her family history. When the bill came, the
insurer said it would cover the service because it was medically necessary but
not at 100%, because she's not yet 50. The result for the couple was the $3,000
bill.
•Know your insurer's specific rules. Also important is to
confirm how your insurer interprets the guidelines.
Mammograms, for example, are a recommended preventive exam for women over 40
every one or two years. In that case insurers have some discretion; one carrier
may pay for the test annually while another will do so only every other
year.
"Talk to your plan to learn about the details of what's covered. They are the
one setting the rules," said Anthony Wright, executive director of Health
Access.
Also remember to stay in your health plan's provider network. Once you see a
doctor who doesn't participate with your plan, you'll be subject to costs, even
if the visit is for a preventive service the law requires insurers to cover in
full.
•Is your visit really preventive? Dr. Kurt Ransohoff, chief
executive of Santa Barbara-based Sansum Clinic, says he increasingly sees people
with high-deductible health plans wanting their medical complaints explored in
the context of a preventive visit to avoid high out-of-pocket costs. But that
doesn't always fly.
"Patients need to understand if they're just coming in for a checkup with
nothing specific or major, it's probably preventive. If they're really coming in
because they're wondering why their hip has been killing them for the last three
months, that's something different," Ransohoff says.
Doctors typically know the difference, he said. "If you have to do more than
a routine physical, you're supposed to bill it as an office visit in addition to
a preventive visit." Ransohoff recommends that patients clearly state the
purpose of their visit when making their appointment so that the patient and
doctor are in agreement.
•Get to the bottom of unexpected bills. If you're sent a
bill for a service you thought was preventive and covered in full, your first
step is to call your doctor, says Cheryl Fish-Parcham, deputy director of health
policy for Families USA, a healthcare advocacy organization in Washington,
D.C.
Talk to the doctor's office about how the visit was billed "and then to the
health plan about why it doesn't think it was preventive," she said.
In cases where a doctor's office or pharmacy is improperly billing, involve
your insurer. Sometimes a customer service representative can get the provider
on the phone and quickly clear up the confusion.
If that doesn't work, file an appeal with your health plan and ask that it
reconsider its initial decision. You also have the right to initiate a
second-level review by an independent third party if your first appeal is
denied.
Brutman has filed an appeal with his insurer in the hope of saving $3,000 he
doesn't believe he should have to pay for the colonoscopy.
"The most frustrating thing is there is no one on the side of the patient,"
he said. "The patient is caught in the middle and will pay the bill at the end
of the day."
Resources and links
•A complete list of preventive health services that should be available
cost-free: HealthCare.gov, http://www.healthcare.gov/what-are-my-preventive-care-benefits
•A tool kit about preventive services, including sample appeals letters: The
National Women's Law Center, http://www.nwlc.org
•Help with insurance problems: Patient Advocate Foundation, http://www.patientadvocate.org
•HMO appeals: California Department of Managed Care, (888) 466-2219 or healthhelp.ca.gov
•Insurance appeals: California Department of Insurance, (800) 927-HELP (4357)
or http://www.insurance.ca.gov
Zamosky writes about healthcare and health insurance.
business@latimes.com
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