AboutMerry Schiff Expertise I am very familar with Medicare and general insurance questions. I can answer general questions about HMO's.
Experience I have been in the medical billing industry for 50 years. I have helped develop software for this industry. I am a consultant to billers and the medical profession.
Organizations I am the Executive Director of NEBA, a medical billing organization with nearly 1000 members.
Education/Credentials I have been teaching medical billing for many years as well as being a published author with Pearson Education. One book on medical billing (nearly 800 pages) and one on HIPAA.
Question I have a health savings account high deductible medical plan that says it covers 100% of the cost of preventative care, other medical costs are covered after I pay a large deductible. My primary care physician told me that I needed a colonoscopy as it was the 5 year anniversary of the previous one. I contacted my insurer, UHC, at least 3 times in advance of the procedure to confirm that it was 100% covered as preventative. Each time I was told that it was, on the last call I provided the code (V76.51, screening colonoscopy) and was told that if this code was used, the colonoscopy was 100% covered. I had the colonoscopy and now UHC has denied the claim as preventative and has applied it to my deductible, meaning I owe over $1700. UHC wouldn’t indicate exactly how it should be coded but said that use of general illness codes and the primary diagnosis was the problem. The codes used were V12.72 (personal history colon polyps; I had one polyp removed at my first colonoscopy 15 years ago); with additional diagnosis codes of 562.10 diverticulosis (I have had this since the first colonoscopy) and the V76.51 code. A supervisor at UHC told me that I should file an appeal unless the claim is resubmitted with proper codes, but the doctor’s office has already resubmitted at least once without success. Any suggestions would be appreciated on what to do on the coding and what the justification is for denying payment on what to me is a clearly preventative procedure.
Answer It does not sound to me that this is preventative. I do not understad why it wasn't covered with the diagnosis under your medical care benefits. Preventative care is not for a prior illness. Because this is submitted with history of illness and the diverticulosis, it would not be preventative. Sorry but the insurance company is correct in this. You should have your physician resubmit this for a regular colonoscopy with the appropriate diagnosis for performing the procedure.
