My first ever doctor bill and it seems to be in error

[Joan.of.the.Arch]

I've just received my first ever doctor bill. It was for a preventative screening done outpatient at a hospital. It appears that my insurance only pays a portion of this procedure when done for diagnostic reasons; yet I was having it as an after age 50 recommended screening with no problems to have spurred it. The doctor submitted the bill for a diagnostic procedure rather than a preventative screening.

The doctor's billing goes through a contracted company, who tells me they will inquire with the doctor and expect to hear back from him in a week. Then they will call me.

Never having had a doctor bill before, much less one that appears to be in error, I'm just a bit apprehensive about how much trouble it will be to get it straightened out.

What have you found? Is it likely I'll have to make multiple calls to the billing company, the doctor's office, the insurance company, and have to bother my primary care doctor to write a letter saying that he had only referred me for preventative screening?

[doxie]

Did your insurance company say they would pay they full amount for preventative screening? Sometimes they don't want to pay at all for preventative stuff. I'd double check that before you press it farther.

First doctor bill at age 50? I guess you are either the picture of health, or have lived in a country with socialized medicine.

[dfeucht]

Did your insurance company say they would pay they full amount for preventative screening? Sometimes they don't want to pay at all for preventative stuff.

They don't get to choose whether they pay preventive screening or not. If preventive is covered by the policy it gets paid. (100% Preventive coverage is mandatory starting 1/1/11 under reform - the defintion of preventive is out there somewhere to review).

It sounds like coding needs to be corrected. I actually didn't have any issues when this has happened. The doc/hospital re-codes it appropriately as a preventive visit and it should get re-submitted to insurance and paid according to the benefit coverage.

[doxie]

They don't get to choose whether they pay preventive screening or not. If preventive is covered by the policy it gets paid. (100% Preventive coverage is mandatory starting 1/1/11 under reform - the defintion of preventive is out there somewhere to review).

I shouldn't have said they "don't want to pay," what I meant was sometimes it's not covered. I didn't realize that was part of the healthcare bill, good to know.

[marvholly]

The required changes coming 1/1/11 are EXACTLY why I have put off my annual Dr. appt from this fall to Jan (actually Feb as 1st I could get), plus I get to 'skip' paying my $300 2010 deductable just by waiting 3 months.

[muexm]

I would call the hospital billing dept first and ask them to reprocess the claim as a preventative screening. If they give you any problems call your insurance company and they will normally handle it. It happens all the time.

[thefamilyfinanceguide]

I am currently in a similar predicament. I had surgery 10 months ago and just received a bill from the hospital because they updated codes with the insurance company over and over the the insurance company kept saying it is not medically necessary. The trip up, the insurance company paid the surgeon fully but not the facility. I called the insurance company and they are robots. They speak in monotone voices and only are programmed to say certain phrases. So, now its on me to get all the paperwork from doctors, facilities, review the insurance benefits, highlight what's covered, etc. etc. and then file an appeals. A lot of work for the obvious written right in the insurance companies own documents.

The point here is to get as much information for all sources as possible. Insurance companies know they are needed, but don't allow their own employees to think on their own. Why work there?

Good Luck To You as I need it to

[Joan.of.the.Arch]

thefam.fin.guide, I hope not to have to talk much to the insurance company. They are very difficult. I sure hate to be actually sick or injured and have to deal with them....

I called them last week to verify that they will cover the next screening I am to have, also an after age 50 thing. First they said the hospital was not in their network when I knew that the very employees of that hospital are on the same plan as I am. Then they said the med school where the image from the screening would be read is also out of network. Again, I know that the employees of that school are on the same insurance plan as I am on. I protested at the impossibility of both being out of network and then the phone clerk back pedaled and said that yes, both those were participating institutions. Good grief. However, I could not get her to verify that my screening (a mammography) was 100% covered. She just kept repeating that the procedure would be "paid to 100% of eligibility." Good grief. I think you can see how that tells me nothing. Is it eligible? How eligible?

PS. No I'm not the picture of health. I just have never had anything to pay but office co-payments since I first became insured at age 26. First we had HMOs, then we had PPOs. Though I have chronic illness, I don't often even need to go to the doctor, and never to the ER or hospital except when I gave birth. Usually I just go for the recommended twice yearly lab tests and then an office visit so that my doctor can informedly re-write my prescriptions...Don't covet my no doctor bills situation, though, as last year we paid $16,130 for insurance alone. Add to that the monthly prescriptions that both my spouse and I take, and you would see we pay out a lot for the little we partake of medical care plus the promise of hospital coverage.

[Homebody]

Joan, it is important they use the V76.12 code for the diagnosis, which denotes a screening mammogram. That along with the correct CPT code of 76092, or it was when I was last doing billing.