A Note To Our Patients Regarding Insurance
Coverage For Screening And Diagnostic Services
Some insurance plans, including Medicare, have very limited coverage for screening services, which may also be know as preventive or wellness services. It is your responsibility to understand your own benefit plan and coverage, as they can vary greatly. River Falls, Ellsworth, and Spring Valley Medical Clinics cannot quote insurance benefits or guarantee insurance coverage for our patients.
All physician practices are obligated to report patient services through coding systems. If we are performing a service or test to screen for a disease or problem (in other words there are no indications the patient might have the disease), we are obligated to code the service as screening. Diagnostic services, which are done because there is some clinical indication for the test (symptom, family history, etc.), are not coded or billed as screening and your insurance coverage might be different.
Lab tests done previously for screening purposes may no longer be considered screening if the results of the prior tests were abnormal.
A procedure such as a colonoscopy or a flexible sigmoidoscopy may initially be ordered as a screening test, but could become diagnostic based upon the findings such as polyp(s) or other biopsy.
Ancillary services such as lab tests, X-rays, EKGs, etc., are separate from the visit and therefore are coded separately, regardless of whether they are done during a routine physical, or an office call.
Maintaining good health is important to controlling health care costs. Preventive care evaluates your overall health, providing guidance on health maintenance before an illness strikes.
It is also important to understand how medical services are billed and what insurers will cover. For example, Medicare, and some other insurance plans, will reimburse for services related to illness but will not cover most preventive service.
Health Care Providers try to maintain high quality patient care at reasonable costs. Their decisions are based on your health, and it is their responsibility to provide you with excellent health care. Your responsibility is to understand your insurance coverage or payment options and to play an active role in your health care decisions.
What is preventive care Services provided to evaluate and maintain your health Medical care focused on preventing future illnesses Screening tests to detect medical conditions before you have symptoms for certain diseases, such as colon and cervical cancer One example of a preventive visit is an annual physical, sometimes called a well-check.
Preventive care and problem-related services are nationally recognized as two different types of health care services. These services are often performed on two separate occasions. Both services, however, can be performed during one visit when it is appropriate and convenient for the patient.
What is preventive care
Services provided to evaluate and maintain your health
Medical care focused on preventing future illnesses
Screening tests to detect medical conditions before you have symptoms for certain diseases, such as colon and cervical cancer
One example of a preventive visit is an annual physical, sometimes called a well-check.
What is a problem-related service
Services provided to evaluate a specific problem and/or illness
Medical care focused on the history of a problem, assessing the problem and treating it.
Diagnostic tests to help your physician find the problem or the cause of a problem, make a diagnosis and develop a treatment plan.
A visit to a Healthcare Provider for a specific illness or injury, such as a sore throat or bad back, is an example of a problem-related service.
What is a problem-related service
Billing and coverage of Combined preventive problem visits
If a River Falls, Spring Valley or Ellsworth Medical Clinic Health Care Provider provides preventive care and evaluates or treats a problem on the same day, two separate services may be billed - a preventive service and a problem service. This billing reflects the actual services provided. Your portion of the bill will depend on your insurance coverage.
If you have questions about which services are covered, please contact your insurance company. If you have questions about your RFMC bill, please contact our insurance department 715-425-6701 or 800-514-9204.