Health Insurance & why you need to take serious time to understand it

[jacklpalmer]

I was not going to post again on this thread and just agree to disagree , but something hilarious happened.
My daughter called me because her insurance ( is now managed by AETNA) denied her child's claim and during her call to them, the agent wanted to argue about who is PRIMARY insurance between two parents.
Not wanting to realize they are primary using the SAME insurance rule they had argued with me about when she was 12.
So this "Training ISSUE " has now spanned over a DECADE.

Jacklpalmer, Are you sure it is a training issue? Maybe the same hack is still training customer service agents or better yet they have not updated their Training manual.

I don't have any special love for Aetna - so be to perfectly honest I'd still buy it's a competency issue with their crew.

Are you sure it's Aetna, though? It's possible she works for a company that is self-funded. Aetna is a pretty common carrier that leases their network for self-funded employer plans. I'm wondering if she is working with a TPA that had the same problem I one I worked at did. Wouldn't be too surprising.

If that's the case, I'm going to be perfectly frank with you - COB issues happen, we just have to deal with them. But fixing them is easy if you're talking to any health insurance professional worth their salt. It really shouldn't be any longer than a 3-5 minute phone call to get it resolved. They may require a form. If so, do it. Not a big deal, really.

If the person she's talking to can't fix it because he/she isn't "getting it," she needs to talk to a supervisor. Then she needs to complain with her human resources/benefit administrator about the poor service their TPA is giving her. Most people at the employer level tend not to know what's going on between their employees and their TPA, so if people don't speak up, things aren't going to change. With luck, her benefit administrator will call in to their TPA's account manager and/or broker and inquire about why it happened and how they're planning to not let it happen again.

[jacklpalmer]

I always try to understand my plan but sometimes I get stumped anyway!

I had a routine Colonoscopy when I turned 50 in Nov 2016. As I understood it, if I went to a facility in our plan and used a doctor in our plan it was 100% covered even if it turned into a diagnostic procedure, instead of routine. So I drove about 35 min away from home to get to a 100% covered facility.

Turns out I had 2 polyps but they were benign and it was still considered routine and I owed nothing.

Fast forward to March 2018, my DH is 54 and had his first routine colonoscopy. We did the same thing went to the 100% covered facility (my DH works in govt and they contract with this hospital so if we go there everything 100% covered).

He has 2 polyps they remove, also beinine but his procedure is coded diagnostic and we owe $245. WTH!! Tried talking to them, nothing, disputed the claim they studied it, still say I owe it was coded correctly diagnostic. I tried to get them to tell me why was mine not coded diagnostic 2 years earlier, yet his was same results 2 years later? Who knows. I paid the $245

I'm so sorry, Trift-t. I just browsed back through this forum and it looks like through all the rest of the hu-bub, I missed your post entirely.

Okay, so you clued into a common issue with preventive services and the colonoscopy is the most common offender of particular - shall we call it a "glitch?" The answer is a little complicated, so bear with me here, I'm going to do my best to describe it.

For what classifies as a "preventive service," a health insurance carrier has to use what is defined by the United States Preventive Task Force, specifically services that have a "grade" of "A" or "B".

A colonoscopy classifies for that, as long as there is no diagnosis. More simply, it's covered as long as they're "just checking." They're not doing a colonoscopy as a diagnostic procedure for someone whom has a diagnosis. Simple so far, right?

Here's where the stupid part comes in. If you go in for a routine colonoscopy, and they find a disorder, guess what? It's now a diagnostic service because there is a diagnosis. So the thing you thought you were going in for and was going to be covered at 100% is now applies under your surgery benefit. And you'll learn that just in time to also learn you likely have a medical condition you'll have to pay even more for.

It's broken. It needs to be fixed. I've been saying it for years, but unfortunately I'm not a politician.

Another thing that is possible is that the hospital billed it with a diagnostic ICD10, such as D12.6 or D37.4 instead of a routine diagnostic code, like Z12.10 or Z84.81.

It sounds like you called the provider, but did you call the insurance carrier to see how the claim was processed? Do you have an EOB for that service?

[Thrif-t]

Another thing that is possible is that the hospital billed it with a diagnostic ICD10, such as D12.6 or D37.4 instead of a routine diagnostic code, like Z12.10 or Z84.81.

It sounds like you called the provider, but did you call the insurance carrier to see how the claim was processed? Do you have an EOB for that service?

No worries and thanks for responding to me. Yes I called/well you have to email, you get no where on the phone, the provider; because when I called the insurer they said it was coded diagnostic and check with provider.

Here's my EOB,no claim numbers on it for me to see how it was coded:

TYPE OF SERVICE
Date of Service: Mar 29, 2018
Outpatient Services
COVERED CHARGES $2,738.21
ALLOWED AMOUNT $2,738.21
MEDICAL MUTUAL PAID $2,492.89
YOUR RESPONSIBILITY $245.32

Details of amounts billed for hospital outpatient services:
All Inclusive Ancillaries $192.21
Laboratory Pathological $285.00
Pharmacy $10.00
Operating Room Amb-Surg $2,251.00
Total Amount Billed $2,738.21
A coinsurance of $245.32 was applied to this claim.

I just got the bill and questioned why was his procedure that progressed the same way mine did, polyps, removal, benign; I got a routine code = free, he got a diagnostic code = pay coinsurance.

When I called the provider to see why the difference between the two of us, they researched it and just came back with because a routine procedure turned into a diagnostic one since polyps were found hence diagnostic code. Which I GET!

I just figured maybe something changed in the plan from 2016 to 2018 that I wasn't up to speed on so I paid.

Wait when did ACA go into effect? Maybe that's the key between the 2 differences. We never had co-insurance until ObamaCare. My DH works for a County Government and has a cadillac plan I believe. But changes have been made maybe(?) to be in compliance with the ACA. I think I just talked myself into understanding what happened. Thanks!!

[jacklpalmer]

The ACA went into effect in 2010, but most of the changes that are important to us as consumers started on 1/1/2014. Are there are any reason codes or remarks on the EOB?

[Thrif-t]

The ACA went into effect in 2010, but most of the changes that are important to us as consumers started on 1/1/2014. Are there are any reason codes or remarks on the EOB?

Nope odd uh? Just that the 245 is applied to the coinsurance. Although I just looked online not at my actual paper copy. But I imagine they should be the same.