Originally Posted by BRENDA28
I'm going to put on my insurance hat (15 + years with the Blues, 8 years with another insurance company). When writing/building the "routine" benefits for insurance, they mean "without evidence of disease or dysfunction". Although the patients will usually call these routine, the way to think of them is as preventive (or preventative).
The most usual routine or preventive labs are, of course, a yearly pap for women, and a PSA for men over 50. There are a number of companies who, as part of the preventive benefits, are now covering other screening tests such as glucose and cholesterol. These are usually on a schedule according to age, and only every so many years. For example, my personal health insurance covers both of those tests every 5 years up to age 50, then yearly after that, with no disease or symptoms (in other words, a "routine" diagnosis). They are covered at 100% with no deductible. However, once the patient has a diagnosis of hyperlipidemia, and is either placed on medication or tries to lower it by diet and exercise, further cholesterol testing is no longer preventive or routine, but because they have a condition. The tests are probably covered, but subject to deductible and coinsurance.
In your examples above, the patients have diagnoses that are the reasons for the lab tests, and it is correct to use those diagnoses, not a "routine" one.
This is often a hard concept to explain to patients, so I hope this helps somewhat.
Lucinda (Cindy) McGarry, CPC-P
Avera Health Plans
Education Office Sioux Falls SD Local Chapter
Past President Sioux Falls SD Local Chapter