Annual physical — not all tests are “preventive”

I’m 57 and get regular annual physicals. The Doctor is part of my network. Part of my annual physical was a blood test, which I assumed was preventive maintenance and therefore covered. I was diagnosed as pre-diabetic which will require semi-annual blood tests. I have another scheduled for May. I ended up having to pay for this blood test. I also was liable for a good chunk of my last colonoscopy about a year and a half ago and this is not a cheap policy. If this is how it is now, then I’ll have to live with it. I just don’t know if the insurance people or the billing office know what they’re doing. Thank you very much for your assistance.

Joe in Maine

Dear Joe In Maine,

Here is what I think is happening.

Even though the blood test is part of your annual physical, it not necessarily on the approved preventive services list. Or, it may be on the list, but not recommended that it be done every year. So, for example, you might be getting your cholesterol checked. This test is considered preventive and would be covered every 5 years for a person your age. If you are having the test every year, it won’t be covered as preventive; it would go onto your deductible, or however your plan covers regular lab tests. The same is probably true for your colonoscopy: they may be preventive tests, but they were more frequent than the plan has to cover.

When your doctor orders tests, you can ask him/her or the office staff to check on your policy’s coverage for it. (Have them call the insurer or call the insurer yourself with your ID number. It’s not accurate to say “Oh, they always cover such-and-such a test.”) You can then know in advance what you will pay, and you can decide whether you want to have these tests done more frequently than the guidelines suggest. There are reasons that people want more frequent testing – risk factors, history of disease, etc. You may find that your doctor orders them out of habit and does not need the higher frequency of testing. Unless there is a good reason to have these tests more often, you are better served to stick with the guidelines. Over testing can lead to over treatment, and cause more harm than benefit.

Linda Riddell

About Linda Riddell

A published author and health policy analyst with 25 years’ experience, Linda Riddell's goal is to alleviate the widespread ailment of not knowing what your health plan can do for you.