Why People Think Prevention is Free (But Then Get Charged When They Shouldn’t)

Under the Affordable Care Act (ACA), preventive care is intended to be covered at 100%. The truth is, however, on average, only one in three adults will access preventive care annually. Why are so many adults not using the one benefit that should be free to them?  

Perhaps it’s because they fear that when they go for a preventive care check-up, it will result in costs they didn’t expect, and may not be able to afford to pay. Recent research shows that commercial health plan claims can result in the below.

Preventive Benefit Abrasion 

How can this be happening? Ultimately, it comes down to how services are reported on medical claims. Medical carriers have developed detailed claims payment policies to separate screening services from surveillance. To simply explain these two dimensions of prevention, “screening” is done to detect conditions early in people not known to have disease, or who may be at risk of disease, whereas surveillance is monitoring patients based on their risks, because of previous findings or family history.  

Health plans have gone to great lengths to pay as little for preventive services as they can, and they use these distinctions in their claims payment policies. Unfortunately, few people understand these differences and, as the research is showing, they end up going in for an annual preventive exam expecting 100% coverage, only to learn otherwise, long after their visit. 

The truth is many people are not experiencing the full benefits of 100% preventive coverage, because they have existing disease or a known risk of disease due to their family history. While the ACA eliminated the pre-existing condition limitations that hindered access to medical insurance, pre-existing conditions seem to have found a new home in the preventive benefit. Surely, there is a better way. 

100% Coverage for Preventive Case is Possible  

EHE Health’s preventive benefit program is designed to avoid all this confusion and fear, ensuring members receive comprehensive preventive care at 100% in-network benefit coverage from high quality physicians. The member benefits through the program’s simplicity, whether they do all their preventive care in one visit, or through multiple visits over the year following their initial preventive exam. If the service is delivered through EHE, there is no need to differentiate between screening or surveillance because it is 100% covered. 

The employer benefits too, as EHE’s bundled pricing model protects against the dramatic variation in costs for medical services, while ensuring their members experience great medical care, elevating their benefit program. The good news is, it’s easy to set up with your third-party administrator too, eliminating the need to dig into those mind-numbing preventive care claim payment guidelines. 

Playing the Long Game 

Think a year, five years, ten years from now – what does your company’s population health look like? Perhaps you’ve lowered healthcare costs and offered healthcare coverage at 100% for your employees. 

Whatever that long-term vision looks like, it requires you to consider equitable care for all your employees. It’s one of the most important changes you can make today that will have positive repercussions for years to come. 

Interested in employee healthcare solutions? Get in touch here.