Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

Providing and Billing for Preventive Services


Under the Affordable Care Act (ACA), specified preventive health services must be offered at no cost to all insured individuals, with special services offered for women and children.

Though many of these services have been required under the law for at least two years, doctors and other eligible healthcare providers have an opportunity to help patients stay healthier while earning additional income for their practice by recommending and scheduling the applicable screenings and counseling for patients.

Some of the covered services include blood pressure screenings for adults aged 18 and older; tobacco screening and cessation interventions; cancer screenings; hearing and vision screenings for children and newborns; and immunizations. Eight new preventive services specifically for women just became part of the ACA mandate effective August 1, 2012. Among these new services required are contraception; breastfeeding supplies and support; gestational diabetes screen; sexually transmitted infections screenings and counseling; and domestic violence screening and counseling.

A fact sheet overview of the preventive services covered under the Affordable Care Act, broken down for adults, children, and women is available in the Newsroom of HealthCare.gov.

Technically, the no cost-sharing services covered under the ACA are ones that have been recommended by such agencies as the U.S. Preventive Services Task Force (USPSTF), the Centers for Disease Control and Prevention (CDC); and the Health Resources and Services Administration (HRSA), and could change in the future based on evolving recommendations. A complete list of those recommendations, some of which are limited by age, gender, or risk factors, are available at the Recommended Preventive Services page on healthcare.gov.

Patients and providers need to be aware, however, that under certain circumstances, insurers may charge copayments and/or coinsurance for these services. According to a Kaiser Family Foundation document, Focus on Health Reform, “so long as the preventive service is performed by an in-network provider, is not billed separately from the office visit, and is the main reason for the office visit, then the visit and the preventive service will be covered by the insurer without cost-sharing.”

However, if the office visit and preventive service are billed separately or if the primary reason for the visit was not preventive, the patient may be required to pay for the office visit. Or if the provider is out of network, the patient may be required to pay for both the office visit and preventive service.

Additionally, if the service is provided to ineligible beneficiaries (based on age, timing of service, gender, pregnancy status, etc.), if the service provided is substantially different and therefore billed by the provider using a different procedure code than allowed for by the insurer’s requirements, or if a diagnosis code indicating a condition other than preventive care is used, the patient may be required to pay for the service.

Providers serving Medicare patients should refer to the Preventive Service Quick Referencefor guidelines on providing and billing for the various preventive services under that program. In an August 28, 2012, Physicians Practice article, “Don’t Forget the Annual Screens for all Medicare Patients”, author Jeff Gatewood estimates that providers could earn as much as $50 per Medicare patient per year for asymptomatic screens. Some screenings, such as the annual alcohol and depression screens, “can be provided and combined during any encounter or with an annual wellness visit or a physical exam,” according to Gatewood.

According to an August 20, 2012, statement by Health and Human Services (HHS) Secretary Kathleen Sebelius, 18 million people with traditional Medicare had received at least one preventive service at no cost to them so far in 2012. In 2011, an estimated 32.5 million Medicare or Medicare Advantage beneficiaries received preventive benefits free of charge.

Understanding and following specific guidelines for billing preventive services to Medicare patients are important for getting properly reimbursed for your work. For instance, Medicare allows for a one-time “initial visit” for Annual Wellness, after which a “subsequent visit” should be billed in the following years. According to Decision Health Daily‘s analysis of Medicare claims statistics from 2011, many providers skipped the initial visit and begin billing subsequent visit, missing out on a potential $55 for each patient. Also, billing alcohol screening/misuse services or sexually transmitted infection screenings for Medicare patients can be complex; providers should review Medicare Learning Network News Flash documents MM7791 and MM7610 for more information on billing those services.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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