Prevention rules introduce new complexity

We’ve blogged before about prevention and the difficulty of determining returns on preventive care investments. Now comes a new wrinkle: The inner details of the reform law. Atlantic Information Systems looks at prevention and health reform in a new article, “Health Reform’s Prevention-Services Rule Perplexes Health Plans With Coverage Mandates Open to Questions.” Here is an excerpt (and perspective from senior clinicial consultant Patricia Zenner):

Zenner cites numerous examples of practical challenges for plans trying to administer the new preventive-coverage mandates. Among them:

  • There are broad CPT codes for laboratory studies, such as an analytical technique called mass spectrometry, “that could test for absolutely anything,” Zenner says, “and there is no way to differentiate it on the claim. That could make it difficult for a plan to show it is providing the required specific screenings for newborns, she says.
  • The rule’s call for mammography screenings every one to two years for women over age 40 still presents a challenge despite coding differences for preventive mammograms and diagnostic mammograms. That is because “something might start out as a screening test and ultimately become a diagnostic test, and the billing process becomes complex,” she explains.
  • The rule calls for Rh factor incompatibility screening for all pregnant women and follow-up testing for women at higher risk. According to practice guidelines, such testing should be done at 24 weeks’ to 28 weeks’ gestation unless the father’s blood type is known to be Rh negative, Zenner says. “But how would you know the father’s status?” she asks. “In this case, I think health plans will just have to pay” for the screening at the first pregnancy visit and again at 24 weeks’ to 28 weeks’ gestation.
  • Various other complications are outlined in the full article.