Understanding the cost of your doctor visit

In the fourth installment of this 4-part series on health care costs, we look at the different types of care to help you better understand what you’ll need to pay.

Understanding your health plan costs can help you choose the right coverage and budget for your health care spending. But what happens if you’re not sure how much your visit to the doctor will cost? Or if you get a bill for a visit you thought was covered by your plan without any cost to you? To avoid financial surprises, it helps to understand the difference between preventive care and diagnostic care or treatment services — and your costs associated with each.

What is preventive care?

If you’re enrolled in a health plan, preventive care visits may be covered at no cost to you, depending on your coverage. The purpose of preventive care is to help keep you healthy and detect possible health problems early on. Some examples of preventive care services may include:

Flu shots
Colorectal screenings or mammograms
Routine physical exams
Regular screenings for blood pressure or cholesterol

What are diagnostic and treatment services?

Any care or service that’s used to diagnose or treat a health problem isn’t considered preventive. These services are given in response to symptoms of a possible health condition, or to treat that condition.

For example, if you have pain in your leg after falling down some steps, your doctor may recommend that you get a test, such as an X-ray, so they can diagnose the issue. Based on the diagnosis, your doctor may also provide or order services to treat your condition — like pain medication for your leg or physical therapy services.

Understand the difference in your costs

What you end up paying for a visit depends on whether you get preventive care or diagnostic or treatment services.

Sometimes you may get a combination of these different types of care. If your doctor provides or orders additional diagnostic or treatment services during the same visit as a preventive service, you may need to pay a copay, coinsurance, or deductible for these additional services.

Preventive care

Example: You’re an adult with high blood pressure and you get your Type 2 diabetes screening.
Cost: No out-of-pocket cost.

Diagnostic or treatment services

Example: Your doctor finds a mole and removes it for testing.
Cost: Because the mole removal and testing are diagnostic, they may result in a bill, such as for a copay, coinsurance, or deductible.

Combination of preventive services and diagnostic or treatment services

Example: At a routine physical exam, your doctor notices your throat is red and irritated. They may order a test to rule out strep throat.
Cost: Your physical exam is considered preventive so you might not pay anything for it, depending on your coverage. However, the strep throat test may be billed as diagnostic. When this happens, you’ll need to pay out-of-pocket for the diagnostic test.

Knowing the difference makes a difference

Your best line of defense against illness is to stay on top of your preventive care. Whether it’s getting your flu shot each year or going in for a routine screening, preventive care is a necessary part of staying healthy.

If you’re not sure whether your latest exam or test is a preventive service or a diagnostic or treatment service, visit kp.org/prevention or call Member Services. And if you get a bill that you may have trouble paying, check with your health plan to see if they offer financial help.