The cost of medical insurance is a hot topic for debate. Over the last few years, I have felt the pinch of increasing insurance premiums and moved to a high deductible plan. You have probably had to make similar adjustments. In this post, I will share one experience that might help you fight some of the spiraling costs of medical care.
I assume more out of pocket costs upfront with a high deductible plan yet there are a few provisions where preventive care is covered 100%. The annual physical is one of them.
It had been several years since having an annual physical. Last year, my doctor said let’s get it on the calendar. Here’s the paperwork to get your blood work. It took six months to get an appointment.
As the appointment approached, I thought I should make a list of things that were affecting my health to discuss with my doctor – some of those minor everyday nagging aches you just kind of deal with. Isn’t that what an annual physical is about – to set a baseline and ward off small things that could snowball quickly left untreated?
At the physical, I brought several of them up. A few weeks earlier I had taken a fall on the ice and landed on my wrist I had broken three years earlier. It was still a little sore and I was getting ready to head to Florida to play some golf. At first he suggested an X-Ray and I opted to wait to see if it got better. He suggested I play golf and if it hurts to stop. If it did not improve, I could revisit the x-ray option upon my return.
The second issue I was experiencing was re-occurring acid reflux. Weight loss, changes in my diet and eating habits (eliminate meals after 8pm) and taking some over the counter medicine would make a big difference. I expected the subject of weight loss to come up during the physical; I had been inching up the scale over the last few years.
A few weeks later, the bill comes in the mail. Since I pay out of pocket first, I scrutinize my bills more closely and notice two office visit charges – $185 and $120 = $305. I called the doctor’s office to inquire; they no longer handle billing so I was told to contact their billing agent.
The billing agent’s response is that they are processing the codes that the physician puts down for them to bill out. It is not up to them to change it. They suggested I call back the doctor’s office and ask them to reconsider what was provided to them.
On my second call to the doctor’s office I asked them to review the billing code with my doctor. A return call said that the billing stood because a diagnosis was made: acid reflux during the physical exam.
I shared my frustration with the office manager. I could understand a separate charge if my health issue required significant time to diagnose; however, our conversation was less than two minutes and I considered a part of the physical exam. Au contraire, according to her, physicals do not include these discussions.
Since when did the definition of a physical change? I have never had this happen before. Who’s responsibility is it to inform the patient that you are now entering into a new visit charge?
The office manager understood my position; I was not the first person to question their practice. Her hands were tied; confidentially she agreed with me.
The next step was to call the billing office again and formally request they review and intercede on my behalf. They said it would take about 7-10 days.
About two weeks later, I decide to call Excellus because I wanted to talk to the ethics department. This situation continued to burn me. I spoke with an informed customer service representative who told me this was not the first time he had heard of extra visit billings. He said the insurance company does not control how the doctor bills. In his opinion, after looking up my records, he agreed the charge was unreasonable.
The next step was to call the billing agent to see if my appeal had been granted. After two weeks, there was no progress or resolution. I informed them that the insurance company had suggested I file a grievance. I told them I would wait awhile longer and if there was no resolution, I would file it.
Here is the information that the insurance company needs if you find yourself in this kind of situation:
- Patient’s name
- Provider’s name
- Date of service
- Procedure code
- Diagnosis code
- Referral number (if applicable)
- Claim number (given to you by the insurance customer service agent)
- Why you disagree with the contract exclusion
- Why it should be covered
- Any documents
- Notations of calls to all parties involved
Today’s update, it has been 45 days and still no decision. The paperwork is hung up in the system. It seems like a no-brainer to me.
Thanks for the info! I am going to a new Dr. tomorrow and will ask if bringing up anything that concerns me will be an extra charge!
This Dr.s’ office sent forms for me to fill out including the”Assignment of Benefits-Financial Agreement which stated,”I herby give lifetime authorization for payment of insurance benefits to be made directly to…. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In the event of default, I agree to pay all costs of collections, and reasonable attorney’s fees.
I have never had to sign a form like this other than the standard authorization of the insurance company to directly pay the physician/office. I feel like I need to have this physician to sign a form stating that He will charge me fairly for his services and maybe I should request that he supply me with a list of codes and what they mean and the charges associated with them. What do you think?
Yes, my doctor has been putting a similar form in front of me! As for the codes, this was a point of frustration for me and if you got the list it would be quite extensive. Doctors generally don’t know the codes, but they do know that what they put down creates a charge. I would focus on your first point. Make sure the doctor informs you when discussions or other diagnosis are going to incur a new charge. BTW – I have never been rebilled for the “extra” charge after contesting it but it took time to do it.
I am trying to verify with my insurance that lab word ordered by my doctor will be covered. I’m told the only way to be sure is if they have the billing code. Billing gave me a code but the insurance says it is not a code. It seems my options are to get the lab work done and risk having to pay the bill myself or not get the lab work done at all. What other options are there when coding is in question?
Esther,
I understand your frustration! As read, I made numerous phone calls. When you said billing gave you the code, I assume you talked to someone in the doctor’s office or their billing service to get the information. If this situation happened to me, I would call again and tell them that the insurance company did not recognize the billing code they provided, could they double check. If they say it is the right code, then I would ask them to call the insurance company directly because you acting as a middle person is not working. They may balk but stand your ground. If they still don’t want to do it, then ask for the manager. In those situations, I just go up the ladder until someone can be of assistance. No one should have to go into a medical situation blindly and most insurance companies want you to be more active in managing your healthcare. Good luck.
Did you ever get this resolved? I had a similar billing experience and I’m trying to figure out where to do with this.
Yes, Debbie it was resolved because I did not pay the part of the bill I was challenging. I believe what happened is the insurance company went back to the doctor and one or the other agreed not to bill me for those services. This would not have happened unless I continued to make phone calls and challenge the charge with my doctor and insurance company. It was time consuming but it paid off.