Carmen Aiken, a resident of Chicago, had scheduled an annual physical exam in July 2023 at a family medicine practice operated by University of Illinois Health. The purpose of the visit was to undergo a routine check-up and complete some necessary blood work.
During the appointment, the doctor recommended that Aiken undergo a Pap smear and testing for sexually transmitted infections, as well as receive the HPV vaccine. Aiken, who had previously tested positive for HPV in 2019 and subsequently cleared the virus, agreed to the recommendations.
In addition to the preventive services, Aiken also required some lab work for medication monitoring. After the examination, Aiken was directed to a different area within the office building to have blood drawn and receive the first dose of the HPV vaccine.
However, after the appointment, Aiken received a bill totaling $1,430.13. This included charges for lab services, professional services, immunization administration, and vaccines.
The issue arose when Aiken’s health insurance provider, BlueCross BlueShield of Illinois, denied coverage for the lab services, stating that they were classified as diagnostic rather than preventive. As a result, Aiken was responsible for 50% of the cost of the outpatient labs performed at a hospital setting.
Despite filing an appeal with the insurer, Aiken was unsuccessful in overturning the decision and ultimately had to pay the bill using a credit card.
The distinction between preventive and diagnostic services is crucial for billing purposes, as it determines whether the patient is responsible for the cost. Preventive services are typically covered at no cost to the patient, while diagnostic services may require copays or deductibles.
The experience left Aiken feeling disheartened and hesitant to seek additional care in the future. The confusion surrounding insurance coverage for preventive services continues to be a challenge for many patients, even 15 years after the implementation of the ACA.
In conclusion, it is essential for patients to be aware of their insurance coverage and to inquire about the cost of services before receiving care. Understanding the difference between preventive and diagnostic services can help avoid unexpected bills. Additionally, advocating for site-neutral payment policies and remaining informed about potential changes in healthcare legislation can help protect patients from financial burdens associated with medical care.
