Preventive vs. diagnostic care: What to know and why it matters

You don’t meet with your primary care physician (PCP) every day. If you’re in good health, you may only see them once a year at your annual check-up or wellness appointment. So when you do have face time with your physician, it makes sense that you’d want to tackle every medical issue and concern.

But not all the care you receive at a medical appointment is the same. Some services help to prevent chronic conditions from developing (preventive care), and some address new symptoms and emerging concerns (diagnostic care). Knowing the type of care you need can help with scheduling the appointment. And understanding the services you received during the visit can prepare you for what to expect when paying your insurance bill.

Here's everything you need to know about preventive versus diagnostic care:

What is preventive care?

Preventive care is for when you are feeling well and are symptom-free. The goal of preventive services is to ensure you stay healthy.

Think of preventive care in terms of your car — getting a tune-up or regular maintenance helps keep more significant problems from happening. The mechanic checks fluid levels and ensures all the car’s systems are running well.

Preventive care is similar to a tune-up — a medical professional measures your vitals and checks to ensure your body is functioning as it should. Preventive services are standard and may include:

  • Checking chronic disease risk factors such as blood sugar, blood pressure and cholesterol
  • Discussing cancer screening tests that are age appropriate
  • Evaluating older adults for fall risk, hearing loss and memory loss
  • Getting routine vaccinations for illnesses such as flu, COVID-19 or pneumonia
  • Measuring height and weight
  • Screening for depression

What is diagnostic care?

Diagnostic care comes into play when something feels wrong, or you have a known medical condition. The services you receive are individualized, depending on what symptoms you have and how you are feeling.

Going back to the car analogy, sometimes you need to bring your car in for a problem unexpectedly — the engine is smoking, you hear a knocking sound or your tire keeps losing air. The mechanic will diagnose the cause and figure out how to fix the problem.

If you’re having symptoms or living with a condition, your PCP will perform tests and services to understand the problem and develop a treatment plan. Diagnostic services can include:

  • Casting and splinting for broken bones and other injuries
  • Controlling chronic pain
  • Discussing new symptoms that indicate injury or illness
  • Managing chronic diseases, such as obesity, diabetes, high cholesterol and high blood pressure

Understanding billing & insurance

The type of care you receive at your appointment affects how the appointment is billed. Preventive care is critical to your health — and helps avoid costly treatment later. Health insurance covers your annual physical and most preventive services when you see an in-network provider — typically without requiring a copay. But you may receive a preventive service that’s not covered (such as vitamin D screening), and insurance doesn’t always pay for diagnostic services.

In some circumstances, your provider may bill your health insurance for preventive care and diagnostic services during the same visit. If you discuss new symptoms or chronic conditions during a check-up or other preventive appointment, you may receive a separate charge for those diagnostic services — which may or may not be covered.

In other cases, the same service can be billed as either preventive or diagnostic — it depends on the reason for the service. A mammogram, for example, is offered as a preventive screening. But it can also be used as a diagnostic tool if there is a reason (such as pain or a detected lump) to believe breast cancer may be present.

When in doubt or if you have questions about your medical billing or insurance, ask your PCP or the office billing department about the preventive and diagnostic services you receive so you won’t be surprised by any medical bills.

Scheduling your medical appointment

When scheduling an appointment with your PCP, it’s critical to make the correct type of appointment. That upfront information helps with billing and allows the nurses and physicians to prepare for your visit.

Depending on the nature of your appointment, it may be billed to your health insurance differently. Common types of appointments include:

  • Behavioral health services
  • Coordination of care for patients with chronic medical conditions
  • Preventive care, which includes immunizations, physicals and routine screenings for cancer and other diseases
  • Same-day sick appointments
  • Travel medicine, including immunizations
  • Well-woman care

If you need more clarification about the type of appointment you need, ask the office staff when you call to schedule your visit.

To schedule preventive or diagnostic services, reach out to your primary care physician.