Colitis and Insurance Coverage

Gayle · Post by **Gayle** » Thu Mar 31, 2011 4:18 pm

NJ,

FWIW -- In the United States all medical billing is done according to what is known as the CPT coding system. This system began with the institution of the US Government's Medicare program back in the late 60's.

CPT stands for Current Procedural Terminology. This very complicated coding system was devised, and is owned and operated by, the American Medical Association.

Most day to day practicing Physicians are to some degree buffaloed by this system, so it is very easy for a code to be mis-classified either by the Physician, or somewhere else in the billing chain -- including of course, the person who does the actual coding for a bill. (One will never know where this has happened.)

It is quite a challenge to get this corrected once this happens -- not impossible -- but QUITE a challenge. When this happens one can expect that any correction will likely take several months. :(( I won't bore everyone with our long story in this regard ... and it was resolved after about 6 months of phone calls and repeated discussions. I finally demanded to meet the person responsible in the billing office in person -- which was when, and how, the case was resolved.

Best of luck with this situation,
Gayle

NJ · Post by NJ » Thu Mar 31, 2011 5:37 pm

Gabes--I see what you're saying about the IBD grouping. Makes sense from their perspective to simplify things.

GrannyH--You're definitely right. I've been persistent thus far, but I'm going to have to work on the patience part. I just don't like having these huge bills hanging over my head. I've kept detailed records and have determined the right coding as you suggested. Now, I just have to make sure my doctor resubmits the claim with the proper codes and that it gets through all the proper channels unaltered.

Gayle--Thanks for the very helpful information. From researching medical coding, I certainly agree that it's complex. In my case, I believe the doctor, himself, coded the procedure correctly but it was later incorrectly altered by his billing manager or someone w/in his office. So far it's been about 2 months of phone calls and stress so hopefully I can resolve the situation as quickly as possible. Seems to be hit or miss--some days I'll speak with very helpful reps at my insurance company and others days it seems like want nothing to do w/ me other than to pressure me to pay up.

NJ · Post by NJ » Sun Jul 17, 2011 3:10 pm

Just to give a quick update, I'm STILL fighting w/ my insurance company. It's been over 5 months since I had the colonoscopy that is at the heart of my coverage dispute. Essentially, there were 3 claims as part of my colonsocopy: The first was payment to the actual GI doctor performing the procedure, the second was payment to the pathologist who reviewed my biopsies, and the third was to the hospital where the procedure was performed.

After having my GI doc properly re-code the procedure as 'preventive'/cancer screening and re-submitting the proper paperwork as well as a letter from him, my insurance company has paid both the GI doc and pathologist at 100% coverage (~ $850). So, there has been positive progress. However, I'm still waiting on the insurance company's determination on the hospital's portion of the bill, which is the most expensive (~ $5000 overall, of which they want me to pay ~$1500).

I'm hopeful the situation will be resolved shortly in my favor given the other two claims based on the same procedure were paid in full. However, until the insurance company cuts a check, I'll still be anxious. It's been a stressful process and I've had to do all the grunt work and really get on my doctor's case to help me, but I've also learned a lot. Moral of the story: Never give up, keep all medical documentation (I mean everything!), and don't be afraid to be polite, but pushy, when you're being given the run-around.

Thanks everyone for all the previous advice. I'll continue to keep you updated and maybe someone can learn from my experience.

Post by **tex** » Sun Jul 17, 2011 4:08 pm

Nathan,

Sorry that you had to go through all that unnecessary aggravation, especially since it was the doctor's fault, in the first place. I hope the insurance company honors their obligation pretty soon. I'm sure they're dragging it out so that they can hang onto their money as long as possible, simply because the law allows it.

Thanks for the update.

Tex

Gayle · Post by **Gayle** » Sun Jul 17, 2011 4:31 pm

Hi again NJ,

Interesting to follow the progess/non-progess you have made with your insurance company regarding your situation.

As to the situation that I was alluding to in March, that was in regard to an office call exam my husband had ... LAST MAY (2010)!!

There were many, many calls last year about this situation, and then we started getting notices from a collection agancy!!! After that I really got persistant about wanting to speak directly with the person responsible for this billing -- at which point we were told that it would be more trouble than it was worth for them to pursue correcting the bill (which was several hundred dollars) and so they were choosing to forgive that bill.

Incidentally, the group of physicians is owned by a Medical Center, and it was the Hospital (Medical Center) that was actually doing the billing here.

Fast forward to May 2011 ... Husband needed exam again this May, and again called Insurance regarding coverage?? During this conversation he mentioned to the person he was speaking with about this situation last year, and that they had refused to pay last year. That person's response was "That shouldn't have happened" "That was a billable item." "We will pay them" -- and they did!! We just got our statement of payment from our insurance this past week!!! ---- 14 months after the claim was generated!!

Don't know what the Medical Center will now do with this, as they now have extra money with no way to balance against an outstanding charge. Wonder if they will refund to us rather than go throught all the work necessary to make things balance this time around???

Don't know if you watch Frasier ...

but this story reminds me of the eposide in which Martin gets extra monry from the cash machine, and Daphne shames him into trying to return it to the bank. LOL!!!

I guess the moral of the story is Hang In There, and keep plugging. The whole medical/insurance thing if OH-SO frustrating when one gets into these binds. But never, ever let it get you down.

Cheers,
Gayle

grannyh · Post by **grannyh** » Sun Jul 17, 2011 5:31 pm

Insurance can give you an ulcer!..LOL Took my insurance over three years to pay my bills on original diagnosis..but in the end they paid.
grannyh

JLH · Post by **JLH** » Sun Jul 17, 2011 7:59 pm

Happy that you have some progress and hope it will all be resolved soon.

Do all y'all know about the MIB?
"Most consumers are well aware of credit reporting agencies. They keep track of how well we pay our bills and manage our credit so lenders can decide whether to loan us the money we need for mortgages, car loans, credit cards and other credit devices.

But most consumer-patients are surprised to learn of the existence of a parallel reporting agency for the health industry, the Medical Information Bureau (MIB) . Originally established in 1902, it serves the information needs of almost 500 health and life insurance companies in North America that seek health, credit and other information about those consumer-patients who request to be insured."

grannyh · Post by **grannyh** » Sun Jul 17, 2011 8:15 pm

JLH,
Didn't know about that database. Can only imagine how it will be increased with all of our personal information once Obamacare is fully implemented... so much for privacy!
grannyh