The difference between preventive and diagnostic care

The fine line between preventive care and diagnostic care

Understanding the line between preventive care and diagnostic care can be tricky sometimes because the exact same test can be used for both purposes.

The main difference comes from why the test is being ordered. Preventive care helps catch problems before you have symptoms. But once a problem is suspected, the care becomes diagnostic.

For example, a mammogram done as a routine screening for someone without any symptoms is considered preventive. Under many health plans, this routine screening may be covered at no cost. However, if that same mammogram is ordered because you or your doctor found a breast lump, it is considered diagnostic.

What the difference means for your wallet

Understanding preventive care vs. diagnostic care is very important for your wallet. Health insurance treats these two categories differently when it comes time to pay the bill.

Most of the time, preventive care services are covered completely by your insurance. If you go to an in-network provider for a routine checkup or screening, you usually do not have to pay anything extra.

Diagnostic care works differently. Because it treats or tracks a specific problem, it usually involves out-of-pocket costs. You may need to pay a flat fee called a copay. You might also have to meet your deductible, or pay a percentage of the total bill, which is known as coinsurance.

Smart steps to save money on your care

Planning ahead can help you avoid surprise medical bills. Before you get a test or screening, you should:

• Ask your doctor questions. Find out exactly why you need the test. Ask your provider directly if they are billing it as a preventive screening or a diagnostic test.
• Stay in your network. Always try to use doctors, labs, and imaging centers that are in your health plan’s network. Doing this helps keep your costs as low as possible. Going to an out-of-network facility could mean paying much higher prices, or you might not have coverage at all.
• Check for prior authorization. Some expensive diagnostic services, like MRIs or CT scans, may need approval from your insurance company first. This is called prior authorization. If you don’t get this approval before the test, your plan might not cover it. Always review your plan benefits before you schedule your visit.