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Screening vs. Diagnostic: What Situation Types Results in a Bill?

Updated: Aug 18, 2023

Although screening tests and diagnostic tests may both result in disease detection, they aren’t the same type of test. And, when it comes to billing, diagnostic tests are done at a cost, while screening tests typically should not result in a bill.

However, you may still get a bill when you undergo a screening test in some situations. Continue reading to learn more about screening vs. diagnostic tests and the situation types that results in a bill.

Screening Tests Vs. Diagnostic Tests

Screening tests are preventative care that enables the early detection and treatment of diseases. They are performed on seemingly healthy individuals to determine their relative risk of developing a health condition.

Diagnostic tests are done to confirm if a patient has a disease. They are usually conducted on symptomatic or ill individuals to provide a diagnosis for their ailments. Diagnostic tests are also conducted when a screening test is positive.

The Cost of Screening Tests Under the ACA

Under the Affordable Healthcare Act (ACA), healthcare providers must deliver preventative services, including screening tests, at zero cost to individuals. This means that insurers are required to cover the screening tests without sharing costs with the patient.

However, the screening test must be done in-network. So, you should ensure that the doctors and other healthcare providers involved in conducting your screening test are in your insurance plan network.

Recently, the ACA updated the list of preventative services healthcare providers must offer individuals at zero cost. The preventative services you can access under the ACA include HIV and cancer screening, suicide risk screening for teenagers, autism screening for children, and more. Check the full list of covered preventative services.

Why Screening Tests Are Done at Zero Cost

Screening tests are preventative care that helps save lives. According to a new report by the U.S. Department of Health & Human Services (HHS), hundreds of millions of Americans now have access to preventative care services and receive screening tests for free.

However, since screening tests are conducted on healthy individuals, not many people would want to pay to have them done. Hence, screening tests are conducted free of charge under the ACA to encourage more people to do them.

A benefit of prevention medicine is mitigating future healthcare costs. Do you know the US spends more on healthcare than any other country? And, one in 10 people have medical debt? Adopting a prevention mindset vs treating symptoms can reduce monetary burden, mental health angst and pave the road for preparation should a screening indicate further investigation.

How Screening Tests Can Become Diagnostic Tests

Despite screening tests being available at zero costs, you may still get a surprise bill in the mail after the procedure. This is because a screening test can become a diagnostic test under certain conditions.

For instance, a routine colonoscopy may end up surprising a patient with an unexpected bill in the thousands, especially when you went in for a screening vs. diagnostic exam. What causes this to happen? The test could be coded and billed as a diagnostic test rather than a screening because a polyp was found during the screening test and removed. However, under the ACA, the US Department of Health and Human Services provided further interpretation that polyp removal is an integral part of the screening process and patients with private insurance should not be charged. To add further confusion, this depends on your plan. Read more here.

Hence, a screening test may be regarded as a diagnostic test when another procedure is done during the screening, such as removing a polyp during a colorectal screening, and it also depends on your insurance plan. Also, having a family history of the disease or getting screened outside the recommended period may result in the test being coded as diagnostic.

4 Tips to Prevent Getting a Surprise Bill After a Screening Test

Apply these tips before undergoing a screening test to ensure the procedure doesn’t get recoded into a diagnostic test.

  1. Reach out to your insurer to confirm that the procedure will be covered without sharing the cost. Also, confirm that all the healthcare professionals involved in the procedure, including the anesthesiologist, are in your network.

  2. Reach out to your insurer to determine when a screening may result in the patient receiving a bill.

  3. Ask questions. Healthcare facilities should provide information on how a screening test can change to a diagnostic test during the informed consent process. So, make sure to ask if the information isn’t provided.

  4. Don’t sign any document in a rush. Request for them ahead of time and have them reviewed before signing. For instance, the fine print may state situations in which a screening procedure would be considered a diagnostic test. By signing the document, you are agreeing to pay the balance not otherwise covered.

If you have already received an unexpected bill for a screening test you thought would result in zero out of pocket, do your research before submitting payment – because it’s usually in the details. Remember, a screening vs. diagnostic bill can be tricky to decipher.

Should you require assistance, contact an advocate in your area or reach out to Medical Bill & Claim Resolution for a consult.

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