Revenue Cycle Insider

Question: Isn’t preventive care implicitly medically necessary?

Massachusetts Subscriber

Answer: Most payers probably aren’t interested in philosophical discussions about the type of care they’ll cover, and they have reams of policies down on paper so providers, patients, and any other stakeholders can find answers.

Cigna, for example, says: “Preventive care may be Medically Necessary, but coverage for Medically Necessary preventive care is governed by terms of the applicable Plan Documents.” The carrier’s definitions of medical necessity (they have four, two of which apply to physicians and two for other healthcare personnel, including differing definitions/requirements for “seniors”) are mostly based on diagnosing and treating problems as they arise, in accordance with general medical standards and practices.

Aetna, as another example, covers many screenings and immunizations as preventive care, saying: “Many of these services are covered as part of physical exams. These include regular checkups and routine gynecological and well-child exams. You won’t have to pay out of pocket for these preventive visits, when provided in network. But these services are generally not preventive if you get them as part of a visit to diagnose, monitor or treat an illness or injury. Then copays, coinsurance and deductibles may apply. Aetna follows the recommendations of national medical societies about how often children, men and women need these services.”

Look at your specific payers’ policies to find out what services they cover under preventive care versus what services are categorized as medical benefits and may be subject to patient payment.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC