Difference Between Problem & Preventive Visits

iStock 000001892617SmallAn annual preventative service is an important part of an overall good health care plan and is covered by most private insurance plans, although different rules apply and it is important to check your carrier's rules.

A preventative visit is different than a problem visit in that its focus is on screening for unknown health problems in a person who feels well. Sometimes it is known as a well woman exam. PAPs, cholesterol screening, arranging mammograms, colonoscopies, bone densities, screening for STDs , screening for blood in the stool, doing a general exam and gyn exam in a well woman, a skin survey, a breast exam and education about prevention of problems that have not yet occurred but for which the patient is at risk, may all be parts of a preventative exam.

A problem visit focuses on a symptoms or sign or problem that the patient is experiencing or a diagnosis that a patient is already known to have. It generally includes a history, a physical exam, discussing of the problem, forming and initial impression, ordering tests and arranging follow-up.

Why make a distinction between problem and preventative exams?

Most insurance payers provide coverage for both problem and preventative visits, but generally there is a limit to preventative care and how often it can be done. There are also strict regulations about what qualifies as preventative care. Often policies and deductibles are different. Some insurance companies allow both a problem visit and a preventative visit on the same day, and some do not. Please make sure that you are aware of your company's policies.  There is a lot of variation and this clinic follows what they feel is in the best interests of the patient and doesn't attempt to keep up with all the variations in insurance policy on this.  The person who initially takes your call to our clinic will help guide you as to whether your visit is booked as a problem visit, a preventative visit, or both.  However, it is impossible to predict ahead of time how the visit will actually be billed, as that depends on what is discussed at the visit, and what services actually take place at the visit. 

Can a provider at Women's Health Connection be my main primary care provider?

Absolutely. Comprehensive training in primary care is part of a board certified Ob/Gyn's training and for many women, their ObGyn is the only physician that they see for several decades of their life unless they develop a complex medical problem. It really depends on your comfort level. Some women appreciate being able to have everything looked after in one place, while others prefer to see us for gynecologic care, problem and preventative, and see another primary care physician for other parts of their care.

What are the common problems that people are seen for at Women's Health Connection?

The providers at Women's Health Connection see a variety of general problems and problems specific to gynecology and urogynecology.

General: Skin problems, cholesterol problems, osteopenia/osteoporosis, thyroid problems, colds/sore throats, insulin resistance, high blood pressure, irritable bowel, low back pain, depression/anxiety, gastro-esophageal reflux, fatigue, chronic pain, urinary tract infections, interstitial cystitis, allergies

Gynecologic: heavy periods, painful periods, ovarian cysts, endometriosis, vaginitis, menopausal symptoms and hormone problems, contraception, sexual problems, fertility problems, polycystic ovarian syndrome, hirsutism, pelvic floor problems, STD checks, fibroids, ectopic pregnancy, recurrent early pregnancy loss, chronic pelvic pain, vulvar itching and dermatitis, vaginal atrophy

Urogynecologic: urinary stress incontinence (leaking), urinary urgency and frequency, overactive bladder, pelvic prolapse (cystocele, rectocele, enterocele, etc)

Does booking my visit as a problem visit or a preventative visit mean that's how it will be billed?  Can I request that "just preventative services" be performed?

Often, the way a visit is booked is the way it is billed, but not always. It depends what actually happens at your visit. If your visit is booked as a preventative, but a significant amount of time is spent on a problem or symptoms, then both will be reported to your insurance payer.  It would be non-compliant for us to report problem services to the insurance carrier as "preventative services".  In addition, even if you tell the office that all you want done is "preventative services", it often cannot be carved out from a combination of both.  It would be unethical for a provider not to follow-up on and discuss problems that are identified at the time of the preventative visit, either based on what the you tell the provider about symptoms and problems you are having, or based on problems that the provider notes on exam.  If the provider spends significant amount of time evaluating and managing, over and above the standard preventative visit, then that, by definition, is a separately identifiable service, from a coding point of view.  There is no way that the schedulers can predict with certainty how the visit will be billed ahead of time, because what is booked, and what actually happens are often very different.  It is disruptive and there is not adequate time, for the provider to stop in the middle of the visit, and discuss when a preventative exam becomes a problem visit, and since the providers are not certified coders, it is only after the documentation is completed that these determination can be made, by a coder reviewing the notes of what actually happened, which is done after the fact.  So please expect that there may be both a problem and preventative component to your visit, (and hence charges to insurance for both), even if it is initially booked as an "annual preventative visit".

What does a preventative exam usually consist of?

For those under ages 13 to 20:

A preventative exam typically consists of a survey of skin exam, thyroid exam, breast exam, abdominal exam and possibly a pelvic exam. A pelvic exam (hyperlink) is usually done on a regular (usually annual) basis if a person under the age of 16 has been sexually active in the past. Preventative counseling may include any number of a variety of topics suggested by the American College of Obstetricians and Gynecologists for this age group. Chlamydia and Gonorrhea testing are automatically done unless specifically declined. HPV is automatically done on any PAPs that are slightly abnormal (see “Abnormal PAP smears” hyperlink). Other tests are done as indicated based on past medical history, family history, review of systems and physical exam. Prior to sexual activity, this may consist of a discussion of general reproductive function and what to expect in terms of body changes and a frank and open discussion of questions related to future gynecologic and sexual concerns. Contraceptive counseling and vaccinations and STD prevention are common topics at this age. Smoking cessation and substance abuse are also not infrequent topics.

For those ages 21 to 39

A preventative exam typically consists of a skin exam, thyroid exam, breast exam, abdominal exam and pelvic exam. Until age 25, Chlamydia and Gonorrhea are checked automatically unless specifically declined. After that it is done as indicated and requested. Cervical screening, ie collection of a PAP smear or screening HPV test, is recommended as a part of the pelvic exam on most patients in this age group on a regular basis. Other tests are recommended ordered as indicated based on past medical history, family history, review of systems and physical exam. Preventative counseling may include any number of a variety of topics suggested by the American College of Obstetricians and Gynecologists for this age group and among other topics include contraceptive counseling, smoking cessation, self breast exams, vaccinations, and other topics.

For those age 40 to 64

A preventative exam typically consists of a skin exam, oral cavity exam, thyroid exam, hearing screen, breast exam, heart and lung exam, abdominal exam, and pelvic exam. Cervical screening, ie collection of a PAP smear or screening HPV test, is recommended as a part of the pelvic exam on most patients in this age group on a regular basis. Mammograms are typically recommended every one to two years after age 40 and yearly after age 50. Bone densities are done based on current guidelines, but usually begin around the age of menopause for most women. Colonoscopies are recommended every 10 years, earlier if risk factors present. Regular cholesterol screening, glucose screening, and thyroid screening are recommended. Chlamydia and gonorrhea are done if indicated based on symptoms or new partners. Cervical screening, ie collection of a PAP smear or screening HPV test, is recommended as a part of the pelvic exam on most patients in this age group on a regular basis. Other tests are ordered on an as needed basis. A variety of preventative health topics may be addressed in counseling around these visits.

For those ages 65 plus

A preventative exam ideally is similar to those ages 40 to 64, except that for many women, Medicare rules now apply. Medicare doesn't cover preventative care, except for a breast and pelvic exam every year and a PAP smear every 2 years (every year if high risk factors present). The rest of the preventative care exam is either paid for out of pocket, or not done. However Medicare does cover problem visits and many women by this point in time have developed some forms of stable chronic problems, or are having symptoms of new problems, and if so these are addressed at the same time, since Medicare does allow a problem visit to be combined with the breast and pelvic exam and PAP.