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 QUESTION: In January 2006 my oncologist ordered a lab test that was not covered under my insurance policy. At the time, I did not know this and was never informed that, in all likelyhood, insurance would not pay for this test. Now, the lab is coming after me to pay for it. Under Texas law, do I have to pay since I was never given an option to opt out of having this test?
ANSWER: Hi, I do not know Texas Law and I am not a lawyer so I cannot advise of any legal advise.
Have you talked to your doctors office? Sometimes there are better ICD9/CPT codes that they can bill with and in which your insurance may cover. For example, sometimes people go in for a routine visit and your visit gets billed as routine and a lot of insurance policies do not cover routine. But, lets say while you were there you discussed other symptoms, etc. with your doctor. Then if say you mentioned headaches, he could resubmit the claim with a diagnosis of headaches which then may be covered under your policy. Usually, to resubmit the claim with a corrected ICD9/CPT code the office needs to indicate it is a corrected claim and send their office notes to support the diagnosis change, in order for the insurance company to review it again. Otherwise, I guess you could talk to your doctor to see if they will help you out since you did not understand that they would be billing for it and now that it is not covered you are stuck with the entire bill. Let me know if you have any more information on it or any further questions. Thanks.
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QUESTION: Thanks for such a quick reply! The test ordered was called OncoType Dx. Apparently, it is considered by the insurance companies as "experimental" and not reliable. This was news to me! But the diagnosis code cannot be changed as breast cancer is still breast cancer! The test was to rate the tumor in my breast for chances of recurrence. So the test is really specific to breast cancer. I just didn't know that insurance companies were not paying for it at that time.
Answer Hi again, I apologize for not replying to your follow up. I had never seen or had one before on this site so didn't realize it was here pending. You know a lot of insurance companies will not even do business in Texas because of their strict guidelines. So, it was denied because it was Experimental? If it was & your doctor did not tell you that it was experimental & could be denied, I would have the dr send in an appeal to your insurance company showing/including any comprehensivee studies or reasoning why he thought it would help you. The more proof the doctor sends of why what he/she choose for you will only support the appeal.
