Top 5 Pitfalls of Employee Health Plans – Part II

One of the key provisions of the Affordable Care Act otherwise known as “Obamacare” allows men, women, and children to seek routine care at no charge.cardiology-test-stethoscope-9251072

You may be wondering what “routine care” encompasses. There are dozens of services that could be considered preventive under a standard employee benefits plan if you know the tricks of the trade.

In the second part of our series, we will discuss some of the most common issues your employees deal with when using their health insurance plan for routine care.

Pitfall #2: 

Getting crushed with a bill even though you thought you were going for a no cost preventive care visit.

How To Avoid:

Medical billing is a daunting task. Unless you are in the medical field, you most likely didn’t know that all doctors and

facilities are required to submit your bill to the insurance company using two little codes.

Code 1 is the “Diagnosis Code” which corresponds to the reason for your visit. Code 2 is the “Procedure Code” which corresponds to the actual service that took place.  These codes are the key to every medical bill.  They are the factors the insurance company uses to determine who pays what.  Incorrect codes are the number one reason your employees will end up with a surprise medical bill.

When your employees schedule a wellness visit, it is important that they make it very clear to the doctor’s office the exact reason for their visit.  The diagnosis code the doctor submits to the insurance company will dictate if the visit will be billed as preventive and cost nothing or billed as something other than preventive and drive up costs. Most wellness visit codes begin with the letter “V” whereas basic office visits are usually just numbers.  The magic words to tell the doctors office are “Bill this as preventive.”

  • Employee health plans are subject to an “Age and Frequency” schedule.
    • For example, a mammogram screening is covered every 2 years after the age of 40 and a colonoscopy is covered every 5 years after the age of 50.  Obtaining these services outside of the normal age bracket or more frequently than stated will result in unwanted medical bills.
  • Did you know that birth control is covered at 100% as preventive care?
    • Birth control is one of the many items that are now covered free of charge by your group health plan. However, the key is to understand this provision applies to “GENERIC” forms only. Generic medications are usually identical to the brand name drugs on the market but are much cheaper to make which ultimately results in lower costs for you. Your group health plan administrator should be able to provide you with a list of all prescriptions that fall under this benefit similar to what CIGNA provides. It is also available on your health plan’s website. If your doctor has prescribed a brand name prescription, ask them if there are generic alternatives you can try.
  • One of THE most frustrating situations I come across is a wellness service turned Diagnostic.
    • In this example, a patient over the age of 50 schedules a colonoscopy.  During the the procedure however, the doctor finds a polyp and removes it. Two months later the patient is staring at a $2,000 bill for what he or she thought was preventive!  because something was discovered during this “routine visit” the doctor is now permitted to bill it as a diagnostic service instead of preventive. It is almost impossible to avoid this situation as most times the doctor does not know what’s to be found until the procedure has begun  However, you should know exactly what your plan covers in these cases beforehand.

What’s next?

Did you know that when you see in network doctors, lots of preventive care services are covered by your insurance plan at no charge? Download our free guide to learn what preventive care services you and your employees are eligible for under your group health insurance plan.


Download Free Guide