Understanding Split Billing: Preventive vs. Medical Visits

When you visit your healthcare provider, the services you receive may fall under different billing categories. One important concept to understand is split billing, which occurs when your visit includes both preventive care and treatment for a medical issue. In these cases, the billing for your visit may be divided into separate charges based on the services provided.

What Is Preventive Care?

Preventive care is focused on maintaining your health and identifying problems before they become serious. Examples include:

• Annual physical exams
• Cancer screenings (e.g., mammograms, colonoscopies)
• Immunizations
• Routine lab work
• Lifestyle counseling (e.g., diet, smoking cessation)

These services are typically covered at 100% by most insurance plans under the Affordable Care Act (ACA), meaning you generally don’t pay anything out of pocket.

What Happens When Medical Concerns Arise?

If, during your preventive visit, you mention a new or existing medical issue—such as high blood pressure, diabetes, skin conditions, or headaches—your provider may evaluate and treat that issue during the same appointment.

In this case, your provider may use split billing, where:

• The preventive portion of your visit remains covered by insurance (usually at no cost to you).
• The medical portion may be billed separately and applied to your deductible and coinsurance based on your plan.

This ensures accurate billing for the additional evaluation and treatment services that go beyond the scope of routine preventive care.

When Is the Entire Visit Billed as a Medical Visit?

If the majority of your appointment is spent addressing medical concerns rather than performing preventive services, the provider may code and bill the entire visit as a medical (non-preventive) appointment. In this case, standard out-of-pocket costs like copays, coinsurance, or deductible charges may apply.

Why Split Billing Happens: CMS Guidelines

Healthcare providers must follow federal billing and coding guidelines mandated by the Centers for Medicare & Medicaid Services (CMS). These rules are designed to:

• Ensure accurate and transparent billing
• Prevent fraud and abuse
• Standardize how services are categorized and reimbursed

Under CMS regulations, providers are required to document the time and nature of services rendered during each visit. If a visit includes both preventive and diagnostic components, each must be billed according to its classification—even if they occur during the same appointment.

What You Can Do as a Patient

To avoid surprises on your bill:

• Ask your provider beforehand whether your visit will include any services beyond routine prevention.
• Review your insurance plan to understand your coverage for preventive and medical services.
• Check your Explanation of Benefits (EOB) to see how services were billed and what you may owe.

If you have questions, feel free call our billing team at 844-735-5615.