Understanding American health insurance and billing can be incredibly confusing, to say the least. Lots of patients find themselves frustrated by unexpected bills, especially if they’ve been told their insurance is in-network for a visit or procedure. At Tia, we’re all about empowering women to make informed decisions about their health—which includes understanding the ins and outs of your coverage. That’s why we created this guide: to demystify insurance and make it easier to navigate billing.

What does "in-network" really mean?

When a healthcare provider is "in-network," it means they have an agreement with your insurance company to offer services at a negotiated rate. In theory, this should result in lower out-of-pocket costs for you as a patient.

But many people don’t realize that just because a provider is in-network, it doesn’t mean everything during your visit will be fully covered by your insurance. The distinction between what is and isn’t covered can result in surprise bills that feel frustrating and unfair. Here are a few important points to keep in mind:

Preventive vs. diagnostic care: Even when visiting an in-network provider, certain services are classified as preventive (which are typically fully covered) while others are considered diagnostic (which often involve copays or deductibles).
Separate billing: In-network coverage doesn’t automatically mean all aspects of care are bundled into one charge. You may receive separate bills for lab work, imaging, or consultations with specialists—services that may have different coverage rules.
Understanding deductibles: Deductible plans are becoming more and more popular because they typically have a cheaper monthly premium or rate. Instead of paying a flat rate or a copay for a healthcare visit, you’re responsible for the total amount until your in-network deductible is met. Once your deductible is met, your insurance plan will begin paying a higher percentage for your care, or for more of your healthcare visits for the year.

These are true across the healthcare system, no matter where you go. Understanding what’s covered under your plan and asking questions can help you manage your healthcare expenses more confidently.

What’s included in a preventive visit?

A preventive visit—often referred to as an annual or wellness exam—is fully covered under most insurance plans. But it’s still important to understand what’s typically included and where additional costs might come from.

A standard preventive exam generally covers:

Routine screenings (e.g., blood pressure, cholesterol, cancer screenings)
Immunizations
Discussion of general health and wellness concerns
Age-appropriate counseling, such as for diet, exercise, and mental health

But if specific medical issues are discussed or treated during the visit—like a mental health concern or a new symptom—these may be considered diagnostic care, which can result in additional charges. To avoid surprise bills, it’s helpful to clarify with your provider whether any new concerns will be classified as diagnostic care.

Understanding your PPO plan: what it covers—and doesn’t

PPO (Preferred Provider Organization) insurance plans offer flexibility when choosing healthcare providers and typically don’t require a referral to see a specialist. While this flexibility allows you to access a wide range of care options, PPO plans also have specific rules about what’s covered and how services are billed.

Here’s how PPO plans cover care:

Preventive care: Typically fully covered without cost-sharing (e.g., annual physicals, vaccinations, and some screenings).
Diagnostic care: Any service aimed at diagnosing or treating a specific condition (e.g., lab tests, imaging, specialist visits) will usually require out-of-pocket costs.

A real-life example: Cate’s preventive visit

Let’s take Cate as an example. She has a PPO plan and is going in for her annual preventive care visit, which is fully covered by her insurance. Cate’s primary concern is her overall health, but she’s also been struggling with acne and wants to discuss it during her visit.

Here’s where things get tricky: acne is a specific medical concern, so it’s considered diagnostic care, not preventive. Even though Cate is at a fully covered wellness visit, the moment she brings up her acne and asks for treatment advice or prescriptions, the conversation moves into diagnostic territory. This could trigger additional billing for the acne consultation.

So, how should Cate approach this to avoid surprise billing?

Set realistic expectations: If Cate plans to discuss any specific symptoms or medical issues during her preventive visit, it’s safe to assume that the visit will be classified as a diagnostic (or "sick") visit and may result in additional charges.
Be prepared for potential costs: Cate should be aware that discussing specific health concerns like acne during her preventive exam might result in a separate bill for diagnostic services, depending on how her insurance processes the claim.

By understanding the difference between preventive and diagnostic care, Cate can better manage her healthcare expenses and avoid unexpected bills.

How billing works after your visit

The process usually involves several steps:

The provider submits a claim: After your appointment, the provider’s office will submit a claim to your insurance company, detailing the services provided.
Insurance processes the claim: Your insurance company will review the claim and determine what is covered under your plan. This is where they apply their rules about preventive vs. diagnostic care, copays, and deductibles.
You receive an Explanation of Benefits (EOB): The EOB is a statement from your insurance company that explains what they paid for and what portion of the bill you’re responsible for. It’s important to remember that the EOB is not a bill, but it gives you a breakdown of the charges.
The provider sends you a bill: If your insurance didn’t cover the entire cost of the visit, you will receive a bill from the provider, indicating what you owe.

From confusion to clarity

Navigating insurance and healthcare billing can be challenging, but having a better understanding of how the system works can help you avoid unexpected costs. By being proactive, asking the right questions, and staying informed about your insurance coverage, you can feel more confident in managing your healthcare expenses.

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