Colonoscopy Not Covered. Should we challenge this?

[Pink Partridge]

I have a hard time believing billing would be handled by a phone call. I'm not in the medical field and I didn't stay at a Holiday Inn last night, but I'm assuming even if the doctor's office called to get approval, if the office files it as a "diagnostic" procedure, it will be treated as such (and then not covered at 100%). If they file as "preventative", then it is covered. Did the office tell you they coded it as preventative? If not, ask them to refile. If so, then call the insurance (or get a copy of the EOB) and complain.

They stood by their claim that they coded it correctly. Then gave a reference number for when they called for coverage. Hoping to get to the bottom of this!

 

[Pink Partridge]

OP, how old was your husband's father when he was diagnosed?

60 years old

 

[Pink Partridge]

Of course, should they find ANYTHING, they can change the billing to “diagnostic” on the spot & ding me for the entire cost.

So shady.

 

[Hikergirl]

I hope you get it cleared up OP.
It is recommended that anyone with a first degree relative with colon cancer have them done beginning at age 40, or 10 years younger than their relative was diagnosed.
I was due for mine last year but put it off. I will be scheduling one after my upcoming appt with my PCP. It never occurred to me that it wouldn't be covered as I'm following the above recommendations which makes it preventative treatment, at least that is what I assumed.
How is it even legal for the insurance company to change the code on their own, wouldn't that at least require consulting with the doctor who performed the procedure?

 

[lanejudy]

I think you may have zeroed in on the issue. The accepted practice is age 50, but now the recommendation is to start doing them at 45. Not sure the health care industry and insurance industry has adopted 45 yet.

THIS ^^^ If your husband's insurance hasn't yet adopted the new recommendations for preventive screening, it doesn't matter what someone else says. Check the documentation of his policy coverage; it should clearly specify when a colonscopy is covered as preventative. The office/clinic/hospital who performed the procedure should have gotten a pre-authorization, and I realize they called but if they don't have it in writing (which they would with a pre-auth), then unfortunately if the policy documentation only states "age 50+" then the insurance is unlikely to re-adjudicate the claim. Get ANYTHING in writing, never just verbal. IF the office/clinic/hospital got it in writing, be sure to get a copy of that to include with your appeal.

Good luck! I've had to fight insurance companies and it isn't fun, nor is it quick. Be sure to submit copies of any documentation (written not verbal), and keep a copy for your own records.

How is it even legal for the insurance company to change the code on their own, wouldn't that at least require consulting with the doctor who performed the procedure?

I don't think anyone has said the insurance company changed a code. Just that the code which may have been used might not be the correct code to get the procedure covered at 100%.

 

[longboard55]

I went thru this, the insurance adjuster was in Malaysia, if you get the picture. You need to send it up the ladder. Preventive colonoscopy is 100% covered, it is the law

 

[JaxDad]

They stood by their claim that they coded it correctly. Then gave a reference number for when they called for coverage. Hoping to get to the bottom of this!

Good one!

 

[Wishing on a star]

I would imagine that the way to have this covered, in this kind of situation, would be to have a PreAuthorization.
The key word would be 'pre'....
If there is come confusion about whether this was preauthorized, you might have some ground to stand on.
If it clearly was not preauthorized by your insurance company, I do not really think you will have any luck getting this paid.

If not, and you are having to pay 15%, I would thankful that I only had to pay that much.

PS: I am over 50... Of course there were the constant demands that I have one.
I have absolutely no history, no problems, etc... And, for me, for several reasons, going thru the prep and going thru this is a real hardship.
Finally, my primary said, do a ColoGuard....
Ended up being charged a LOT just for that. (Don't know if we ever paid)
Of course, I get the same blurry, low-quality copy, sheet that does not give any numbers or details, just 'positive', that almost everybody else gets...
This is a huge CASH COW...
I did the colonoscopy, and absolutely nothing, at all, showed up.... Nothing....

I personally would not waste my time and money on ColoGuard, when it is really is just part of our CASH COW medical system.

 

[Hikergirl]

I don't think anyone has said the insurance company changed a code. Just that the code which may have been used might not be the correct code to get the procedure covered at 100%.

I'm going what the OP said, they spoke to someone at the office and they said it was coded correctly and that the insurance co could have seen the age of the OP and changed it, or something to that effect. Actually it was that they may have decided due to age that the OP had to pay the deductible. I assume that means somewhere in their system a code would have had to to be changed in order to generate a bill to the OP.

 

[lanejudy]

I'm going what the OP said, they spoke to someone at the office and they said it was coded correctly and that the insurance co could have seen the age of the OP and changed it, or something to that effect. Actually it was that they may have decided due to age that the OP had to pay the deductible. I assume that means somewhere in their system a code would have had to to be changed in order to generate a bill to the OP.

The insurance company did not -- cannot -- change the coding submitting on a claim. What happened in OP's situation is the doctor's office received information before the procedure that it would be covered 100%. Once the claim was submitted, the insurance company is only claiming an 85% coverage with 15% co-insurance plus deductible from the patient. What "changed" was the stated level of coverage, not a billing code. What we don't know is if the doctor's office did an official "pre-authorization" resulting in the "will be covered 100%" or if that was verbal, like a phone call. Unfortunately, if it's not in writing as a pre-authorization, there could well have been some missing information or misunderstanding on either end about some aspect of the patient/procedure/coverage. Written pre-authorization is always the way to get such information.

 

[mommy2allyandaveri]

Doesn't hurt to file a grievance. I work on disputes just like this for a living (literally this exact thing, all the time). If they can verify you were told it would only be $40, the remainder should be waived. If the referring provider or GI provider states it was preventive only, it should be waived. The worst they can do is deny you.

Sometimes it really is coded incorrectly or there was a mistake made along the way.

 

[mom2rtk]

I have a similar family history & have had several preventative colonoscopies pre-50. Of course, should they find ANYTHING, they can change the billing to “diagnostic” on the spot & ding me for the entire cost.

I feel it’s a bit like taking your car in for warranty work on the transmission. If they happen to notice the wiper fluid is low while it’s there, they’re no longer required to cover the transmission under warranty. Outside of the medical industry, such practices would be illegal.

Funny you should mention that. We're in the midst of an issue just like this with our 2012 Ford Focus. We got an transmission error message and have had some transmission related symptoms. Transmission is covered on our extended warranty, so no problem right? Well, maybe. It is covered but only after they tear down the transmission to prove that it's a transmission problem and not an electrical problem. Cost of the transmission teardown? $1K. Which we'll be on the hook for if it turns out to be an electrical problem. Won't know until they tear it down.

 

[Gumbo4x4]

Funny you should mention that. We're in the midst of an issue just like this with our 2012 Ford Focus. We got an transmission error message and have had some transmission related symptoms. Transmission is covered on our extended warranty, so no problem right? Well, maybe. It is covered but only after they tear down the transmission to prove that it's a transmission problem and not an electrical problem. Cost of the transmission teardown? $1K. Which we'll be on the hook for if it turns out to be an electrical problem. Won't know until they tear it down.

Ugh. Issues with the dual clutch pack? Had that replaced on our 2014 Focus & it needs to be done again, but now we’re out of warranty.

 

[mom2rtk]

Ugh. Issues with the dual clutch pack? Had that replaced on our 2014 Focus & it needs to be done again, but now we’re out of warranty.

I think that's what I heard.

 

[Gumbo4x4]

I think that's what I heard.

It’s a common issue with the car. There’s a class action settlement available if you get stuck with the bill.

 

[mom2rtk]

It’s a common issue with the car. There’s a class action settlement available if you get stuck with the bill.

Thanks! I'll check it out if we get stuck.

 

[The Mystery Machine]

Husband is 48 years old. He saw a new physician for a physical and the doctor said he should get a colonoscopy due to his father’s death due to colon cancer. Colonoscopy is scheduled. Office doing procedure says it will be $40. That is it. Procedure was a breeze. No polyps found. Come back in 5 years.


We received a bill from the office. It is our deductible and then 15% on top of that. Called insurance company. Lady on phone says “Must be a mistake. Let’s put it in for review”.

Letter comes yesterday saying “Non-routine Colorectal Cancer screening is processed at 85/15 subject to deductible”.

Non-Routine?


Grrr. He would have waited until January to have this done had they been more clear on this. Why was this non-routine if doctor suggested it for preventative screening? He is not 50. But even office doing it said it would be $40, and they had access to his age.


So, insurance experts, does his father’s death from colon cancer make this a preventative scope?


Is it even worth it to challenge this decision?

I wouldn't but my husband would.

I had my first colonoscopy at 41. I insisted, GI did it, even though she was rolling eyes and saying if she found polyps it would not be covered.

Short story, I had pre cancerous polyps. She said I saved my own life.

I am happy your dh had none. That is awesome!

 

[Gumbo4x4]

Thanks! I'll check it out if we get stuck.

Hopefully, they won’t try to colonoscopy you

 

[MrsPete]

So they admit to insurance fraud and involve you in insurance fraud?

I have a hard time feeling any sympathy for insurance companies. They raise their premiums every year, then try to avoid paying when you have a bill. I'm perfectly willing to say whatever's necessary -- to use whatever term's appropriate -- to "play the game".

Similar to your story: I had pneumonia two years in a row, and the doctor recommended the pneumonia shot for me. I wasn't yet 50, so insurance wouldn't pay. I paid out of pocket and haven't had pneumonia since. I'm due for another shot next year, and I'm old enough to qualify now, but -- if they don't pay -- I will pay out of pocket. Not gladly, not without filing a grievance, but I will pay.

In the end she had $15,000 worth of services for the $75 copay at the ER and then we paid $800 for a $1,500 colonoscopy.

Again, I have a hard time feeling bad for the insurance company. I pay 19% of my income for insurance -- that's more than we pay for housing and groceries combined. It's BY FAR the biggest line in our budget, yet most months we don't use our insurance at all.

 

[kdonnel]

I have a hard time feeling any sympathy for insurance companies. They raise their premiums every year, then try to avoid paying when you have a bill. I'm perfectly willing to say whatever's necessary -- to use whatever term's appropriate -- to "play the game".

Similar to your story: I had pneumonia two years in a row, and the doctor recommended the pneumonia shot for me. I wasn't yet 50, so insurance wouldn't pay. I paid out of pocket and haven't had pneumonia since. I'm due for another shot next year, and I'm old enough to qualify now, but -- if they don't pay -- I will pay out of pocket. Not gladly, not without filing a grievance, but I will pay.

Again, I have a hard time feeling bad for the insurance company. I pay 19% of my income for insurance -- that's more than we pay for housing and groceries combined. It's BY FAR the biggest line in our budget, yet most months we don't use our insurance at all.

Sliperly slope.

Our society works because we have rules and people know and follow the rules.

You are advocating for anarchy.

If you don’t like the rules, protest the rules in a legal manner. Don’t commit fraud in the name of good.