Colitis and Insurance Coverage

NJ · Post by NJ » Wed Mar 30, 2011 6:45 pm

Hi everyone,

I haven't been active on the boards for a while, but I'm back to see if anyone can answer my questions regarding insurance coverage for a colonoscopy.

Background: I was diagnosed with Ulcerative Colitis (UC) in 2003 after experiencing symptoms and undergoing a colonoscopy. The diagnosis, specifically, was Pancolitis--meaning my entire large intestine and rectum are inflamed. I was told at the time that because I have Pancolitis my risk for colon cancer is much higher than the general population. As such, beginning 8 years from the time of my initial diagnosis, I would be due for a repeat colonoscopy followed by additional colonoscopies every 2 years for the rest of my life. Because of my '03 diagnosis, 8 years put me due for a colonoscopy this year.

So...thanks to the new health care bill I was able to receive insurance coverage through my state's pre-existing condition insurance plan. Armed w/ my new coverage, I made an appointment w/ a GI doc who agreed that I needed to have a colonoscopy to check on the state of my disease. I called my insurance company to verify the colonoscopy would be covered and was told that it would be covered 100% w/ no deductible payment by me as long as the doctor's office coded the procedure as 'routine and preventive' as opposed to 'diagnostic.' During this conversation, I explained that I already have UC and therefore the procedure was not diagnostic in nature, but rather preventive since I was adhering to the scheduled timetable I was given for getting colonoscopies. Again, I was told that the fact that I have UC would not affect the 100% coverage for the colonoscopy because the procedure was essentially preventive maintenance of a disease. I passed this information on to my GI doc's office and re-iterated their need to code the procedure correctly as preventive and routine.

Fast forward a few weeks and I'd successfully had the procedure. Good news was the inflammation wasn't bad and that my diet has done a great job of controlling it w/out meds. Bad news is that suddenly I started receiving 'explanations of benefits' from my insurance company showing that they weren't covering the procedure 100% as promised, but were only covering their obligated amount beyond my large deductible. The EOB's were soon followed by bills from the hospital, GI Doc, and pathologist showing that I owed them a lot of money.

Freaking out, I called my insurance company and was told the GI doc had coded the procedure as 'diagnostic,' instead of 'preventive/routine,' which means they won't cover the procedure 100%. I then called the GI doc and explained myself to his staff who told me they would 're-code' my claim and send it on to my insurance company. The process is still ongoing, but it's frustrating and I can't get any kind of idea as to where the claims now stand and what are the odds the procedure will end up being covered 100%. Needless to say, I wouldn't have had the colonoscopy w/out believing it to be 100% covered because I simply don't have the money to pay for it. The vibe I'm getting from my insurance company when I call is basically 'you're out of luck, now pay up.' They don't make it sound promising that they will pay and all of this grief is due to my doctor's improper coding.

Given all that, and thank you for reading this far, I'm just wondering if any of you have had difficulties getting colonoscopies covered by your insurance companies and, if you did have problems, what did you do about it? I realize UC and MC are different, but I think MC patients also have to have colonoscopies every now and then. Also, if any of you have experience disputing claims with or filing appeals with insurance companies any advice would be much appreciated.

I'm beyond frustrated because I did my best to verify 100% coverage before my procedure--with my GI doc, w/ the hospital, and also w/ my insurance company. However, none of the 3 would put their statements of 100% coverage in writing and now I'm essentially left with my word against theirs. They broke their promise of coverage, but I don't know what recourse I have to get them to pay. Even when I call customer service, there is a recorded message that states something like: "Advice given is not a guarantee of payment." So basically my insurance company is saying its reps can say whatever they like to patients, but it means nothing. I've documented my calls with the insurance company but I'm not sure that means anything if they believe they don't have to back up what they say.

I feel like I should be in a healthcare reform ad. I'd appreciate any insights you guys have in dealing w/ insurance companies and how I can best go about resolving this if they ultimately say they won't pay to cover my procedure as promised.

Thank you.

Gloria · Post by **Gloria** » Wed Mar 30, 2011 7:30 pm

My experience with insurance companies is that they usually either explain or change things to my satisfaction. It seems that your problem is an incorrect diagnosis, not the insurance's coverage. I would think that once the doctor changes the diagnosis, they will cover the colonoscopy 100%.

Let us know what happens. Everything seems to be in a state of flux with the new health care regulations.

Gloria

NJ · Post by NJ » Wed Mar 30, 2011 7:43 pm

Gloria,

Thank you for the response. You're correct in saying that the problem seems to be w/ the diagnosis being coded incorrectly. My concern is all the hoops I'm having to jump through to get the coding corrected, which really shouldn't be this difficult. Well, there's that concern, and also the massive bills appearing in my mailbox, but so far I've been successful in getting my accounts put on hold while disputing the claims.

I will continue to update as I learn more, but if anyone else has any opinions/experience/thoughts please share them.

TooManyHats · Post by **TooManyHats** » Wed Mar 30, 2011 8:16 pm

Once you have a diagnosis, that diagnosis is always used when coding the bills for payment. I would deal directly with your state's Insurance Commission. It was always amazing how efficient my insurance company got when I got them involved.

NJ · Post by NJ » Wed Mar 30, 2011 11:21 pm

Arlene,

Thanks for your response. I've started looking in to my state's Insurance Commission and how they might be able to help me. I'm hoping I won't have to include them in this mess and that my insurance company will resolve this amicably, but if need be it's good to know I have other resources. Hopefully my insurance company will also be intimidated by the Insurance Commission if I do have to go that route.

jmayk8 · Post by **jmayk8** » Thu Mar 31, 2011 5:41 am

I deal with insurance in my dental office. They are a HUGE pain and do whatever they can to dely payment on their end. However, in my opinion..It was the fault of your GI's office by incorrectly coding your procedure after you already explained to them what needed to be done. If they sent a correction to the Ins co., you should be all set but, will probably take a few weeks bc like i said earlier, insurance co like to delay payment. However, i do think it's strange that they said it would be paid 100% w/out a deductable, I have never seen that before...
good luck!

NJ · Post by NJ » Thu Mar 31, 2011 10:30 am

JMayk,

Thanks for the info. I think you're right, it's going to be a long battle with my insurance company to get them to pay the correct amount. My feeling is that once things are in their favor (ie. improper coding), they are reluctant to correct the error w/out overwhelming evidence (medical notes, etc.), time, and effort.

The reason the colonoscopy would be covered 100% as I understand it is mostly due to the new healthcare reform bill, which mandates that insurance companies 100% cover preventive procedures including such things as mammograms, pap smears, colonoscopies, etc. In my case, I already have ulcerative colitis and thus a much higher risk for colon cancer--making it necessary for me to have a colonoscopy 8 years after my initial diagnosis (so I was due in 2011) and then every 2 years for the rest of my life. I can't imagine it gets any more preventive than that. I have a high probability of colon cancer and the colonoscopies are necessary to check for cancer. It boggles my mind that the insurance company could consider that anything other than preventive.

However, I really do think that's the problem. Even though I received assurances from my insurance company that the procedure would be 100% covered since it was preventive screening in relation to my UC, I believe they're trying to do everything they can to bend the spirit of the law to say instead that the colonoscopy was somehow diagnostic in nature related to my UC. You see, the law is primarily geared towards individuals 50 years or older who need to receive a colonoscopy to screen for cancer because of their age. It doesn't specifically state that the preventive coverage only applies to older patients, but I get the impression that my insurance company is trying to argue that a UC patient as young as myself isn't covered under the new preventive treatment regulations. In my opinion, this is just another case of insurance companies behaving badly and in opposition of providing what should be their goal--quality, affordable healthcare.

I'm going to keep fighting and I really appreciate all of your information and support. Thanks, everyone.

TooManyHats · Post by **TooManyHats** » Thu Mar 31, 2011 12:37 pm

Next time you need one, go to a new doctor, and don't mention your UC. TaDa! Covered 100%. It's unfortunate, but both can play that game.

NJ · Post by NJ » Thu Mar 31, 2011 12:54 pm

Arlene,

You and I think alike. I've definitely contemplated going that route when I need my next colonoscopy in 2 years. Unfortunately, I am forced to disclose my UC diagnosis since I am not in the age range (>50) where preventive colonoscopies are offered w/out question. If I simply ask for a colonoscopy for cancer screening, I'm certain the doctors would simply tell me I'm too young for regular screenings UNLESS I have a family history of colon cancer (I don't) or some form of inflammatory bowel disease (which obviously I do). At that point, I'd have to come clean, acknowledge my UC, and hope the doctors and insurance company treated me fairly and in accordance w/ the law.

If nothing else, I'm learning a lot from this experience and I'll be able to help people in the future who are struggling to get fair treatment from their insurance companies. Just have to keep fighting the good fight for now.

I appreciate your comments, thank you.

Gabes-Apg · Post by **Gabes-Apg** » Thu Mar 31, 2011 1:21 pm

NJ
similar issue here in Oz as i am under the age of 50 there are costs to have most tests. I think one big part of the issue is that the insurance companies must base their assessments for the coding on the published articles by specialists.

there are quite a few GI specialists that believe MC or UC is 'older persons condition' (My GI even said this to me when giving me my diagnosis.
when i went for my bone density scan the practitoner looked up their classfiication and told me it said that the test would be free for persons over the age of 50 with medically diagnosed IBD. we discussed what are the classification based on and it is a combo of published research and information provided by the associations of specialists

given that about 1 in 20 people in this forum get a good specialist, i think we are pushing poop uphill to get the specialists to change their beliefs

TooManyHats · Post by **TooManyHats** » Thu Mar 31, 2011 2:30 pm

I saw this on CBS and had a good chuckle out of it. I thought others might appreciate it, though I doubt even that would make me rush out to have another colonoscopy.

http://www.youtube.com/watch?v=yM-DUoZc5ls

NJ · Post by NJ » Thu Mar 31, 2011 3:02 pm

Gabes,

That's very interesting info. I wasn't familiar with insurance companies basing their coding assessments on the published articles of specialists. If that's truly the case here in the US, too, I hope they're at least keeping up to date w/ the latest published research and findings. Otherwise, the coverage provided might be lagging behind necessary treatments.

I'm surprised to hear that UC and MC are thought of in Australia as 'older persons conditions' because, at least w/ UC, I've always been told by doctors here in the US that UC is commonly initially diagnosed in people between the ages of 19-30. I fit that profile, as I was diagnosed at 19. I'll have to inquire more as to whether my age is affecting coverage in areas outside of colonoscopies, which it very well may be.

Arlene--I watched the video and it gave me a good laugh. I hadn't seen it before, but I'm glad CBS is helping to raise awareness. After my experience, I'd be happy to have CBS pay to fly me to NYC to get scoped. Although, given the laxatives you have to drink the night before a scope, I don't think the luxury or location of the hotel would be fully appreciated--unless it included some kind of amazingly comfortable toilet. =)

TooManyHats · Post by **TooManyHats** » Thu Mar 31, 2011 3:06 pm

You wouldn't even be able to eat the food at that fancy hotel! What a waste!

grannyh · Post by **grannyh** » Thu Mar 31, 2011 3:16 pm

Stress is not good for you. Have spent over a year, several times, getting codes corrected and bills fully paid by insurance.. you just have to be patient and persistent..and get copies of everything. At one point I had the codes listed on the spreadsheet I keep for medical bills and knew when something was coded wrong:)

Find out what the proper code is.. then make sure the bill has be submitted again to the insurance company. I always get a copy of my bills and keep them..heck I get copies of everything..tests, bills...
grannyh

Gabes-Apg · Post by **Gabes-Apg** » Thu Mar 31, 2011 3:42 pm

NJ - I think the issue is not the data regarding ages but maybe the 'IBD' grouping....

my suspicion is that for ease of system management, conditions are grouped a bit so MC, UC and Crohns would all come under the title of medically diagnosed IBD.