So freakin MAD--anyone have health insurance expertise?

[specka]

We have great health insurance coverage, so my husband and I went to the dr.'s office last month for a routine physical and blood work just to check and see if we were healthy. While I was there I mentioned that we were going to TTC next year sometime. She gave me some information, we talked about some other things and then I got my blood work done. Well, I get a big old bill in the mail and when I called my insurance to figure out why it wasn't fully covered, they tell me it was sent through as an "infertility consultation" which is only 50% covered by my insurance!

I never even mentioned infertility, just that we were gonna try next year! So anyways, I called the billing office at the dr.'s to get them to resend the claim or whatever and I can hear her typing up something for a while and she says she will set it up for review and she will call me back. I ask her how long I can expect and she says a week and a half--well my BILL is due on Nov. 2nd!

Should I pay and if it is reviewed as wrongful will someone pay me back? I've never had something like this happen before. Like I said, my husband went to the exact same dr and got the exact same lab work done and was fully covered! So mad!

[Guest]

Don't pay it. Call your insurance company and tell them it is not an infertility consultation and that your doctor is going to resend the claim.

No need to get your blood pressure up just yet. People make mistakes all the time.

[MarginOfError]

Everytime I've disputed a claim, they've told me not to pay until they send me notification.

[specka]

I wonder if I should call the actual doctor's office. I guess I'm a little afraid that for some weird reason my doctor interpreted my visit as a "family Planning consultation" even though I didn't talk about fertility at all. Just that we were going to TTC next year. I know it's a mistake but it's not like they put in the wrong code or something. It would be one thing if it was put in as something completely out of this world like "acupuncture" or something. Not sure specifically how to fight this thing and I wish I could solve this thing faster. A week and a half seems a little over the top.

[BadWolf]

Nope. Don't pay it (or it will take 6mo-6years to get repaid).

1) Tell you insurance co it was a billing code error (over the phone = write the persons name or ID # on the bill / copy for your records

2) Send bill in marked "Incorrect Billing Code / Disputed" on the bill

3) Have your doctors office rebill under the correct code

((This is usually reeeeally easy. "Hey Jane, my physical last week was billed as an infertility consult. Can you fix that?"))

4) Check with your insurance co next month to confirm it was altered in their system.

HIGHLY UNLIKELY:

In the bizarre turn of events that your insurance company doesn't immediately change to the correct code AND sends you to collections... ALL you have to do ( snort. "all". Sorry) is dispute within 2 weeks (by email) and it will stay off your credit report for 6mo while the error is sorted. EVEN MORE UNLIKELY: If it ends up on your credit report, you just email both sets of info: Original person you spoke with, and disputing claim, and the credit beauro erases the claim like it was never there. That it would reach that point is keeeerazy unlikely. But if it did, your credit is protected.

DISPUTE LETTER

On 0/00/0000 my doctors office accidentally miscoded 'infertility consult' instead of 'annual physical'. We are not currently even trying to get pregnant. It was a clerical error that is in the process of being rectified. I do not owe $000, as my insurance covers annual physicals at 00%. I owed $00. Which was paid in full at time of service.

___________

My exhusband changed jobs 3x during our sons hospitalization. I had over 70 service dates (and hundreds of coding) errors I had to wade through. Ugh. By and large 'fat fingering' a code happens so often that its as easy to fix as 2 phone calls. In the event, though, that things go nuts... You can bog down their beurocracy / make it work for you until its a moot point and the error is corrected.

Edited October 23, 2012 by BadWolf
Had to fix a double negative. (2 wrongs = Right = Reeeally wrong)

[slamjet]

I wonder if I should call the actual doctor's office. I guess I'm a little afraid that for some weird reason my doctor interpreted my visit as a "family Planning consultation" even though I didn't talk about fertility at all. Just that we were going to TTC next year. I know it's a mistake but it's not like they put in the wrong code or something. It would be one thing if it was put in as something completely out of this world like "acupuncture" or something. Not sure specifically how to fight this thing and I wish I could solve this thing faster. A week and a half seems a little over the top.

As a biller, I think there are some things to understand here:

- Generally, corrected claims are not sent electronically. They are paper claims and can take up to 60 days to process. This is one reason why it takes a long time to fix.

- When you call the insurance company, always get two pieces of information: the representatives name and the reference number. This way, if there is a dispute as to what was said, you can give them both and tell them to check. We've had them go back to the recording and whenever they did that, we prevailed.

- The software used to check you in has a field where they tag what type of and the reason for the visit. The Dr may go off this but the billers most likely do.

- Billing software pop up suggestions. If someone hits enter too soon, it will put in the wrong code.

- The billing service are usually outsourced. They only know what is sent to them. Even then, we're finding that there are some really shoddy billing services out there.

- Insurances companies are usually willing to work with you to fix any problems. It may take some time and a bunch of transfered calls, but it can be resolved in your favor.

[specka]

- Generally, corrected claims are not sent electronically. They are paper claims and can take up to 60 days to process. This is one reason why it takes a long time to fix.

- When you call the insurance company, always get two pieces of information: the representatives name and the reference number. This way, if there is a dispute as to what was said, you can give them both and tell them to check. We've had them go back to the recording and whenever they did that, we prevailed.

- The software used to check you in has a field where they tag what type of and the reason for the visit. The Dr may go off this but the billers most likely do.

- Billing software pop up suggestions. If someone hits enter too soon, it will put in the wrong code.

- The billing service are usually outsourced. They only know what is sent to them. Even then, we're finding that there are some really shoddy billing services out there.

- Insurances companies are usually willing to work with you to fix any problems. It may take some time and a bunch of transfered calls, but it can be resolved in your favor.

I called my insurance co again and they said pretty much exactly word for word what you said. It started with my Dr. telling them to bill for "infertility consultation/family planning" I called dr.'s office and left a message with a secretary who was very helpful. Here's to hoping that it'll get resolved and I don't have to worry about this anymore (and my dr. gets back to me fairly soon). Until then, I won't pay a dime of the bill. Praying for a good outcome.

[Sharky]

This is kind of a "step back" but I'd reccommend you get a copy of your benefits plan & make sure that Infertility treatment/Family planning is only covered at 50% & if there are any exceptions to this.

Sometimes Family Planning thru a GP or your Primary Care will be covered as a regular office visit while thru a specialist it will be limited. But the insurance pays from the billing codes, not necessarily noting that the doctor was or was not a specialist.

I encounter this frequently with my current insurance. My Primary Care is technically a specialists in that he is an internist, so my insurance sometimes pays at the specialist level where I have a $40 co-pay & sometimes they pay at the PCP level where I have no co-pay. It usually has to do with what billing code that is used but per the plan everything during a PCP visit is covered without a co-pay.

Another Consideration:

We had a large national insurance plan many years ago so we thought we were pretty good as far as ethics & paying according to the plan etc.

Routine doc visits etc were never a problem though anytime a "proceedure" was billed the insurance either denied saying "no coverage" or put it under "deductible" even though the plan benefits specified otherwise.

We'd dispute it with the insurance, providing quotations form the benefits plan documents & then the insurance would correct it & pay the claim.

Turns out the employer had put us into the system as a being employed thru a "remote location" rather then thru the "home office" so the benefits coverage were sligtly different. "Remote Location" employees had limited benefits.

When we'd appeal the claim they'd confirm the correct information with the employer but they never corrected it in the system, so every major claim was processed incorrectly.

We ran into the same problem mid-year when the prescription benefits cap was reached - the plan we were suppose to be on had no cap. That was when we learned that the employer had made the error & the insurance was simply processing claims based on that information.

So it took a while but we did finally get the information in the system corrected so taht claims were being processed correctly after that.

[applepansy]

Be careful because If you don't pay its your credit rating that will take the hit not the insurance company's.

[Sharky]

Be careful because If you don't pay its your credit rating that will take the hit not the insurance company's.

This is based on my personal experience & experience helping/working with a non-profit helping individuals learn budgeting & getting assistance & refi etc in these difficult financial times ..... I'm not a legal or financial expert so don't take this as coming from one:

"MED1" listings on your credit report do not count against your score under current (new in the last 3 years) regulations. Even if they are in collections.

If you get sued for non-payment & a judgement issued against you, then the judgement will hit your score as then it is no longer a "MED1".

("MED1" is simply the Credit Report reference to a medical bill. Most of the normal information disclosed can not be due to HIPPA, so they simply reference it as "MED1").

Also:

Once a "MED1" bill is paid, even if paid a year late or discharged in bankruptcy, you can ask the Credit Bureau to verify the accuracy of the "MED1" report.

They then will contact the medical provider & in most cases the medical provider can not disclose or confirm or verify an account that has been satisfied or is no longer in collections (Pt Confidentiality laws again).

If the provider does not confirm or verify the accuracy of the report, then the credit bureau must remove it from your file.

So, in most cases a "MED1" or a medical debt report to a credit bureau does not effect your score. It would, however, come into play if say you wanted to buy a house & the lender pulled & reviewed the actuall report not just the score & there it was, showing as unpaid.

Most doctors & medical providers will work with you if you let them know that you are appealing the decision of the insurance company or if they are refiling the claim.

It's those people that don't talk about it with the provider that end up with credit bureau reports being filed.

[pam]

Just a heads up. I've been a medical insurance adjuster and have paid medical claims. Your doctor's office may be required to send in the notes from that office visit since there is a change in the diagnosis. Whenever there was a dispute regarding the non payment of a portion or when a diagnosis was changed, we required the medical notes from the doctor to have reviewed.

[dahlia]

Nope. Don't pay it (or it will take 6mo-6years to get repaid).

We can stop right there. Don't pay the disputed bill. They will take forever to refund your money, and big organizations being what they are, what if you have to fight this for years because some bozo can't get the record straight? Better for you to have your money than for them to have it.

[Sharky]

We can stop right there. Don't pay the disputed bill. They will take forever to refund your money, and big organizations being what they are, what if you have to fight this for years because some bozo can't get the record straight? Better for you to have your money than for them to have it.

The reality is....

one: services were rendered

&

two: The patient is financially responsible for the bill, not the insurance.

If the insurance paid according to the plicy, then there really is very little to dispute.

I think it is wonderful that the docs billing office is willing to change billing codes & resubmit it to the insurance. Not every doc office would be so willing to do that.

Ultimately though, regaurdless of being insured or not, the financial responsibility falls to the patient that received the services.

[specka]

My doctor (or the office for that matter) never called me back. I think I might call back tomorrow if still no reply. BTW EVERYTHING is covered 100% (with $20 copay) in my benefits EXCEPT "infertility consultation," which is indeed 50%. And this was not a specialist, but in fact a GP. (I didn't know that that even mattered in some cases..hmmph).

You would think that the doctor would review and go "hmm...I can see how this was supposed to billed as a physical exam let's help a sister out and bill it as that instead of what I originally put." But whatever, we'll see I guess.

The crazy thing is, is my husband did the same exam on the same day and got the same blood work/vaccinations. All of his were covered but because I mention we want to start a family next year and can I get some prenatal vitamins suddenly it is an infertility consultation.

To be honest the bill is expensive, but not HUGE. If it goes unresolved I might just pay it. I've had a medical bill on my credit a while back and it DESTROYED my credit. Just barely been able to pull my score back up.