"Preventative" vs "Diagnostic"

Your insurance says that services you thought «preventive» or «preventative» are indeed «diagnostic». 

What is the difference? Why should you care? Do you truly owe your Doctor that bill?

A. The Differences

1. Cost-wise

By law, «Preventive» or «preventative» care is free to patients.

It makes sense: if you catch something early enough, it will cost less to treat. It won't take as long. The measures of treatment will be more conservative, and cheaper. Because insurances pay less money to address and treat the issue, the savings are passed on to you.

«Diagnostic» services are not free. You may have a copay, or a share of cost: deductible or co-insurance. Because of the level of expertise, the time that the doctor will spend, the complexity of having to figure out a diagnosis, and the best treatment for the best outcome, the fee payable to your doctor becomes (a lot) higher. You, the patient, would be liable for all or a portion of that cost as a result.

2. Clinically

«Preventive care» aims at identifying and addressing an illness, sickness or issue as early as possible to reduce your risk of aggravation or it becoming chronic. Early detection and promoting a healthy lifestyle help improve your overall health and ensure optimum outcomes.

«Diagnostic» means that there is an interpretation of symptoms or data. There are already signs, symptoms or recent test results that make your doctor suspect you could have an underlining condition or that you are sick and need further treatment. A diagnosis must be established, with an appropriate course of treatment.

The next level after diagnostic would be «therapeutic». That means supervising a treatment or cure to get you healthy again. Therapeutic services are much higher level than diagnostic. However, they are both subject to the same terms of coverage and potential patient liability. These are not free services.

B. What to know and do?

When billing your insurance, your doctor must indicate the exact reason for your visit and code it to the highest level of accuracy. 

Should you take advantage of a «preventive» visit to get checked for a new symptom, discuss an established condition, or even get any kind of treatment at all? That level of care and medical expertise will be higher and no longer free. Make sure not to mix the type of visit.

Circumstances may change a «preventive» service to «diagnostic». Let's say you go for a diagnostic routine colonoscopy, the procedure reveals perfect health. You should pay nothing. But if, during a preventative colonoscopy, the Doctorr finds suspicious growths and tissue samples are sent to the pathologist, the procedure might now be coded as «diagnostic». There is a problem that must be identified and potentially treated. That is no longer free preventive care.

In many cases, insurances will not consider even follow ups, or, for example, mammograms once every six months after you've had chemo or surgery, as «preventive» because you are not considered out of remission until five years after end of treatment. Even though technically you may just go for checkups to make sure that a condition or a cancer, for example, has not returned, your insurance could still consider those services to be diagnostic, not preventative.

Remind the staff and doctor that this is a «preventive» appointment, or ask your doctor to explain why he/she has to upcode the visit to «diagnostic».

If the insurance Explanation of Benefits shows a liability, I would make a call to the office, or file an appeal. Mistakes happen, but doctors are bound to code according to different legal mandates and rules, and insurances must follow the Law. Unfortunately, sometimes they need a little push and a reminder.