Preventive Visit vs. Office Visit: What You Need to Know

What is the difference between a preventive visit and an office visit?

Can you be charged for both in the same visit?

At first glance, a physical and an office visit may seem the same, but there is a difference.

Knowing the difference between a preventive visit and an office visit can be confusing, especially if you schedule a preventive visit and end up receiving treatment for a certain health issue, like blood pressure concerns or frequent headaches.

It is important to understand the differences between the two, because it may affect your costs.

Let’s look at the main differences.

Preventive Visit: Annual Checkups Focused on Living Well

A preventive visit is a yearly appointment intended to prevent illnesses and detect health concerns early, before symptoms are noticeable. Depending on your specific insurance plan, this type of visit may be called an annual physical, well-child exam, Medicare wellness exam or welcome to Medicare visit. In terms of cost, insurance companies generally cover preventive care services at no cost to patients.

The purpose of a preventive visit appointment is to review your overall health and well-being. Depending on your age, services may include:

• Complete physical exam
• Blood pressure, blood glucose and cholesterol screening tests
• Pelvic exams, pap smear
• Prostate and colorectal cancer screenings
• Sexually-transmitted disease testing
• A thorough review of your general health and well-being
• Immunization review and update
• Developmental screenings

“Each visit is unique, and there isn’t a standard lab panel or order set that everyone will automatically need,” said Dr. Angela Larson, medical director at Olympic Medical Physicians. “Preventive visits are an opportunity to discuss care areas and share lifestyle modifications to establish a long-term health plan. We work as a team with our patients to build trust and help align their health goals.”

Office Visits: Getting Well with Problem-Focused Care

An office visit is focused on treatment and returning you to wellness. These visits are designed to discuss new or existing health issues, concerns, worries or symptoms, and insurance companies usually require a co-pay.

An office visit may be:

• An appointment to discuss specific, new or existing health problems, such as diabetes, pain, medication adjustment and refills, chronic conditions, high blood pressure, etc.
• Your provider may then prescribe medication, order additional tests like lab work or X-rays, refer you to a specialist or discuss other treatment options.
• Depending on your benefits, an office visit usually results in additional costs to you.

Based on the definitions above, you may be wondering if the same appointment can be considered both a preventive and an office visit? The answer is, yes.

On occasion, one appointment can meet the requirements for both types of visits. If this is the case, your provider will submit a charge for both a preventive visit and an office visit. If your preventive visit includes consultation or treatment for a specific condition, your provider is legally required to document additional medical services, and depending on your insurance may result in additional charges that are not fully covered.

So, what does this mean for you?

While combining a preventive visit and an office visit will save you time by eliminating an extra appointment, it may also affect your costs. Providers must bill your visit based on both the reason you initially scheduled the appointment and what is done during the appointment. It’s important to remember that when you see your provider for a physical, something more than a general evaluation may result in unplanned out-of-pocket costs for you based on your benefit plan.

For these reasons, OMP recommends you schedule your preventive visits and office visits separately.

Things to keep in mind:

• Review your insurance plan’s summary of benefits before your appointment to understand what your insurance company will or will not cover.
• When scheduling a preventive care appointment, clearly state that you would like to schedule a “Routine Preventive Exam,” “Well Child Check,” or “Screening Physical” to the clinic can prepare appropriately for your visit.
• When you talk with your provider, let them know that you are there for a routine preventive exam, or if you need to speak to your provider about a specific concern that may require treatment.

If you have additional questions about preventive and office visits and the costs associated with them, you can review your Summary of Benefits from your insurance plan. If you have questions about whether your visit is considered a preventative visit or an office visit, our call center representatives at OMC (360-565-0999) can also assist you when your schedule your appointment.