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Why Isn’t My “Free” Preventive Health Care Free?

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In my opinion, one of the best changes made by the Affordable Care Act is the mandate that requires health plans to provide certain specified preventive services without imposing any cost sharing.  This is sometimes referred to as “free” preventive care.  As a result of this mandate, deductibles, copays, coinsurance, and other cost sharing may not be imposed on the specified preventive services if they are provided by an in-network provider. 

The thing that is so great about free preventive care is that it results in better health outcomes for employees and their families, while, at the same time, saving employers from paying larger health claims when illnesses are not diagnosed early. 

Unfortunately, there are still some glitches with receiving “free” preventive care.  My husband and I recently turned 50, which qualified us to receive free preventive colonoscopies under our group health plan.  Unfortunately, our medical providers incorrectly coded both of our procedures. 

In my husband’s case, the provider coded his procedure and the related anesthesia as being preventive care.  However, they miscoded the related hospital charges as being non-preventive.  In my case, the same provider coded my procedure and the hospital charges as being preventive, but they miscoded the anesthesia as being non-preventive. 

My husband and I are both covered by a high deductible health plan.  When we received the bills, we were disappointed to discover that our “free” preventive care was not, in fact, free.  My husband’s bill showed him owing $1,300, while mine showed that I owed $150.  Luckily, as an employee benefits attorney, I knew that both procedures were supposed to be completely free of charge, because the services had been provided by in-network providers.  It took numerous calls to the providers and our claims administrator to get the claims paid correctly.  However, my experience made me think about participants who do not understand the rules as well as I do.  They may not know to fight to get the free preventive care they deserve.

What Might Employers Do?

My struggle to get free preventive care leaves me wondering whether employers might be able to do something to help employees get the free preventive coverage to which they are entitled.  One thing employers might do is send a notice to employees regarding free preventive care, and explain that doctors may frequently miscode these services.  Employers may also wish to highlight that preventive care services from an out-of-network provider are generally not free.  Employers might also audit preventive care claims to look for coding errors made by providers. 

What Might Providers Do?

Medical providers may need to be more careful when they code preventive services.  Not only would providers be paid more quickly if they coded preventive care correctly, but it would also save participants from having to battle to get free preventive care.

This issue is important because participants who have a bad experience when they try to get free preventive care may be less inclined to utilize such benefits in the future.  This is a problem that needs to get fixed, because preventive care may save lives.