AboutLinda Woolsteen Expertise I can help you with questions about health insurance. If you feel your insurance company is mistreating you. Are they telling you they are checking eligibity, pre-existing, etc. Or you just don`t understand how your insurance works or don`t understand what a PPO is.. I can help you.
Experience
Past/Present clients One company I worked for I was the underwriter for the Academy of Medicine of Cleveland and the Ohio Bar Association. I was also a supervisor of our customer service department.
Question My wife recently went in for her annual gyno exam. About a month later, we recieved a letter from her insurer with a list of uncovered charges and a warning that we were about to get a bill for $1500. Turns out, these were for blood tests from a lab (HIV test was all my wife consented to) and a physical (which my wife didn't not give informed consent to).
She recently started a new job, and it turns out they don't cover anything preventive during the 1st year on the job. And because the physical and lab work were coded as preventive, the insurer will not pay.
My wife recently talked to someone at the insurance company, and she said that if the doctor would change the coding, they'd probably pay. I don't know anything about coding, so how likely is this? How would we ask the doctor? Is there a way to code a physical and blood work as anything other than preventive?
Answer Hi!
Well, there are a couple of things here. HIV test? was this for her employer? Meaning her job might require that she have it done? If it is for employment a lot of times it would not be covered anyway. Just like truck drivers have to get a physical for their CDL and/or employer routinely and that is not covered.
About the coding... the provider is suppose to bill for what they found. For example, say your wife wanted to go in for a routine check up and lets say she has a routine benefit of $150 per cal yr on her policy which pays 100% if billed as routine. She may have went in thinking it was her routine physical, but during her physical the doctor found something wrong.. at that point it is not a routine physical anymore, the doctor would bill with a diagnostic code instead of a routine code.
So.... if the doctor or providers did not find anything wrong with your wife they would then bill with a routine code and then the insurance company checks to see what type of routine coverage, if any, she has on her policy.
If she mentioned anything to the doctor that day such as cramping, excessive bleeding or anything then it would or should be documented in his notes for that her on that day and they (the doctors office) would then have a legitimate reason to send a corrected claim to her insurance company. They have to state that it is a corrected claim and resubmit along with office notes from that day, to support their diagnosis change. A lot of times the girls in the doctors office will just resubmit after changing the code and when the insurance company gets it the examiners will deny it as a duplicate claim since they had already received a claim for her on that date of service from that provider. Gyn offices are also known to bill for mental nervous and or weight loss diagnosis codes and usually, if covered, mental nervous is a iimited benefit and weight loss is usually not covered at all under most policies. Thus, your wife would want to watch what she is telling the doctor when she is in the office if she does not want such things to go in her file.
The lab gets the diagnosis code to bill with from the doctor that sent her for the lab work so if the diagnosis code is going to be changed, the doctors office will also need to inform the lab so that they can also resubmit the claim. (The doctors office notes are sufficient of course for their claim as well).
$1500 seems pretty high. If you have a PPO policy, make sure both bills went through the PPO network for repricing first. However, on the other hand, if it is a denied claim, the providers (doctor, lab, etc) do not have to take the PPO adjustment if there is one. ( A lot of times they do not know if they are suppose to or not and still write off the PPO adjustment) so even if you have to end up paying the bill at least you will save some money from the PPO adjustment.
