Cancer preventive versus diagnostic exams: What to know about insurance coverage

You may only see your doctor when you’re not feeling well. But, treating your illness usually costs more than preventing it.

That’s one reason why the Affordable Care Act grants free preventive care. But what falls under prevention? And what exactly are insurers expected to pay?

To answer these questions, you must first understand the difference between a preventive and diagnostic exam.

If you’re symptom-free, it’s a preventive exam

A preventive exam is done when you have no signs of illness. It includes screening exams, wellness checkups and patient counseling to prevent possible health problems.

Under the Affordable Care Act, insurance plans should cover certain preventive services without billing you. So, you shouldn’t have to pay a copayment or share in the cost of the service (known as coinsurance).

Free cancer screening exams and prevention services include:

• Breast cancer chemoprevention counseling
• Colorectal cancer screening
• Nutrition counseling for those with higher chronic disease risk
• Obesity screening and counseling
• Immunizations, including the Human Papilloma Virus (HPV) vaccine
• Pap tests
• HPV tests
• Smoking cessation help
• Mammograms

If you have symptoms, it’s a diagnostic exam

When you’re sick or you’ve noticed an unusual change in your body, your doctor does a diagnostic exam. The purpose of this exam is to find the cause of your symptoms.

Diagnostic exams require a co-pay and other fees depending on your insurance.

“During a diagnostic exam, your doctor performs a more detailed examination of your body,” says Therese Bevers, M.D., medical director of MD Anderson’s Cancer Prevention Center. “The results of this exam should tell your doctor what’s happening in your body. Your doctor can then prescribe the right treatment, if needed.”

For example, a screening mammogram is a simpler exam than a diagnostic mammogram. A screening mammogram uses a low dose of radiation. It also gives your doctor a quick view of your breast -- just enough to see if there’s anything out of the ordinary.

If your screening mammogram spots a potential problem, your doctor will order a diagnostic mammogram. This exam involves more detailed images of your breast. And, you’ll be exposed to a slightly higher dose of radiation.

Preventive exams can turn into diagnostic exams

It gets complicated when your free preventive exam turns into a diagnostic exam during a single visit. When this happens, you can end up with medical charges.

“Sometimes, patients come in for a screening exam and during the visit, something suspicious comes up,” Bevers says. “At this point, the visit either becomes a diagnostic visit or the doctor schedules the patient to come back in for a follow-up diagnostic visit.”

For example, during a colonoscopy, a colorectal cancer screening exam, a doctor may find polyps. The doctor can instantly remove the polyp and send it in for biopsy. Doing this prevents the patient from having to return for a follow-up diagnostic colonoscopy.

But now, the free colonoscopy becomes a diagnostic exam. So, it’s no longer fully covered by your insurance. And, depending on whether or not you’ve met your deductible for the year, your co-pay could vary.

The colonoscopy and clinical breast exam are two screening exams that can convert into diagnostic tests while you’re on the exam table.

The Pap test and fecal occult blood test (FOBT) are purely screening exams. If Pap test results are abnormal, the follow-up diagnostic exam is a colposcopy with possible biopsy. If FOBT test results are abnormal, the follow-up exam is a colonoscopy or a diagnostic colonoscopy.

Know what questions to ask

Ask your insurance provider the questions below before your next appointment. That way you’ll be prepared for any possible expenses.

• If my doctor doesn’t find any problems during my preventive exam, will I be charged a co-pay or deductible?
• If my doctor does a diagnostic exam, what charges should I expect?
• What additional costs I should be aware of?

Talk to your doctor before your exam, so you’ll have no surprises at the end of your visit.

• Ask your doctor to let you know if your preventive exam becomes a diagnostic exam.
• Request to speak with someone about charges or additional expenses if your doctor orders a diagnostic exam.

“Cancer screening exams can help find cancer at an early stage when the disease is easier to treat,” Bevers says. “So, it’s good that these exams are affordable for all.”

So, don’t postpone your next checkup. Ask the right questions and stay informed. And, you’ll always be financially prepared for your visit.

Request an appointment at MD Anderson's Lyda Hill Cancer Prevention Center online or call 877-632-6789.