How to fight health insurance claim denial? (US edition)

May 9, 2016 11:21 AM

I had a tubal ligation/IUD removal earlier this year (salpingectomy, to be precise), and was told by multiple insurance company reps that it was covered at 100% because it's considered preventative birth control. Months later, United has denied the claim saying that it was a diagnostic procedure. I've already appealed once and only have one more chance and have no idea what to do differently this time. Meanwhile, the doctor's offices want their money, and rightly so. What is the best strategy to get United to cover this?

United has been *so very* unhelpful, and the billing offices don't seem to be much help so far, either. I am able to pay out of pocket, but furious that they are trying to weasel out of their obligation to cover birth control procedures. How could this possibly be diagnostic?!?
If it's a billing code issue can that be changed after the fact? If I start making payments myself will that negate any claims I have with United?
Any advice is appreciated here, thank you.
Oh and I did see a post from before these laws went into effect, but if I missed something else please feel free to link it. Thank you!

posted by PaulaSchultz to Health & Fitness (13 answers total)

Because this procedure is not a diagnostic procedure at all, I would start with the possibility that your doctor's office billed it incorrectly. They can definitely submit it again with different codes. Calling them and asking them to look into this is a good first step.

Did you get an EOB that shows which codes the procedure was submitted under? Have that in hand when you talk to the doctor's office.
posted by something something at 11:29 AM on May 9, 2016 [11 favorites]

I had a similar issue with United, and found a rep who told me the doctor used the wrong code. She told me what code it needed to be, or what issue (in my case it was bone density and mammo, and the dr had put down a code they didn't like).

The gist was: I had to find out the correct code, call the doctor's office, and ask them to switch it in their system and resubmit to United. After that, it went down to my regular co-pay ($20).

I would escalate to a supervisor at United, and tell them you want the correct code so that your doctor can change it and fix it.

There was another issue they had that the United rep was able to fix on her end, but this one was considered a doctor error (mistaken code).
posted by Marie Mon Dieu at 12:03 PM on May 9, 2016 [5 favorites]

Is your provider in network with United? If so, they are the ones who should be fighting the insurance company for payment, not you.

Sometimes a doctor's office staff will be the ones hassling you for payment without (conveniently) providing you with the contact information for the hospital billing department that would be more effective in following up through their back channels with the insurance company. A last ditch effort, or at least one more phone number to try to find someone who can help, would be going through the hospital where the procedure was performed to reach the billing office instead of the doctor's office.
posted by telegraph at 12:08 PM on May 9, 2016 [1 favorite]

Your state's insurance commissioner may be helpful as well.

Try not to assume they are trying to weasel out of it. Try to assume it is an honest error. You will get better results if you contact them with an attitude of "I am so confused. Y'all told me it would be covered 100% and now it has been denied. Surely, this is a mistake?" than if you call with an attitude of "You lying rat bastards!" No matter what words you choose to use, your real opinions tend to show through.

I worked in insurance. Errors happen. It is a big bureaucracy. The rules are different from one state to another and they are dealing with a constant state of information overload and, yeah, sometimes the forms are not filled out correctly.
posted by Michele in California at 12:27 PM on May 9, 2016 [3 favorites]

I had to fight a different insurance (BCBS) company for something else and finally figured out that the doc 's office had listed what they did in the wrong order which made it look like a routine annual test was diagnostic. Make sure everything is listed in the proper sequence. Once that got straightened out they paid up.
posted by mareli at 12:31 PM on May 9, 2016 [1 favorite]

Yes, it sounds like a coding issue. A salpingectomy is the removal of a fallopian tube--this would usually be done in the event of an ectopic pregnancy or other pathological condition. What you had done is a tubal ligation (cutting and tying/cauterizing both fallopian tubes).

Last fall, I believe that all US practices switched from ICD-9 to ICD-10 codes for medical billing, and the transition was not a universally smooth one. My guess is that someone punched in the wrong diagnosis and code for you, so the claim is being rejected. You should definitely contact the office where you had your TL (and/or their billing department) and get it straightened out. Good luck!
posted by stillmoving at 12:32 PM on May 9, 2016 [2 favorites]

Have you talked to your doctor's office about the issue? They may see that they could have coded it differently or should have declared it as a necessary procedure, etc.

On the insurance end, can you escalate? In my experience with Aetna, the first agent who answered the phone wasn't helpful and I had to escalate to someone who was actually helpful.
posted by AppleTurnover at 12:47 PM on May 9, 2016

Every time I have ever had an issue like this, it always came down to how the doctor's office coded the procedure. Yes they can resubmit with revised codes, it's totally normal.

Basically since the insurance company isn't present at the procedure, they can only accept or deny based on what the doctor's office tells them they did. If the doctor's office coded it wrong, there's nothing you can tell the insurance company to fix it - the doctor's office needs to fix it.
posted by antimony at 12:50 PM on May 9, 2016 [3 favorites]

Agree with everyone saying this is likely a coding issue, where the billing department sent the wrong code to the insurance company. I have had similar issues and, with one exception, the doctor or hospital has had to change something on their end and resubmit. On one occasion there was 6 months of back and forth, but eventually the claim was paid.

Make sure you alert the billing offices of your doctors - that six month back-and-forth bill was almost sent to collections, but I asked the billing department of the hospital to put collections on hold after they resubmitted the claim. The person I spoke to said that things like this happen every single day.
posted by bedhead at 1:17 PM on May 9, 2016 [1 favorite]

Hi there, coder here, though not on the outpatient side. Please note, what I'm saying is based on your info; I do not know what is documented in your record.

It's possible that the codes were not sequenced appropriately-did you have any signs or symptoms, pain, swelling, etc, or was it that you wanted to get rid of the IUD and get the ligation? If they put a symptom code first, United might be arguing that it was treatment.

In theory, your first listed code should start with a Z. I'm looking at my encoder, and it has z30.2 listed for encounter for sterilization, and z30.432 for the removal of the IUD. Was your surgical center freestanding, or are they affiliated with a hospital? If they're with a hospital, try to get in touch with the coding department; coding and billing rarely communicated w each other where I was. (If they don't have a direct connection to coding from the main number, ask for HIM dept or medical records)If they're on their own, odds are good the same people do the charging and the billing. As long as you have your medical record or account number, they should be able to tell you what codes went to bill. Resequencing and rebilling isn't the end of the world for us, and we absolutely want to be sure we're getting it right.
posted by jacy at 3:06 PM on May 9, 2016 [9 favorites]

Find out what code it was submitted under. Find out what code it should have been submitted under. Find out if the doctors office has any paperwork from the insurance carrier explicitly authorizing the procedure and get a copy of it and find out what code is in the letter. Get on the phone with the insurance company and explain patiently what the problem is and ask how to fix it. Call back 7 more times. Keep notes of every call and write down the name of every one you speak with and what they tell you. I've had some luck, when things got extremely infuriating, with pretending to myself that I was a very nice little old lady who would never, ever lose her temper and swear at the insurance representative. I also, when someone told me something that didn't make sense, said, "I'm so sorry, I don't really understand what you're trying to tell me. Could you please explain that to me using different words?"
posted by bq at 4:18 PM on May 9, 2016 [1 favorite]

Regarding this: A salpingectomy is the removal of a fallopian tube--this would usually be done in the event of an ectopic pregnancy or other pathological condition. What you had done is a tubal ligation (cutting and tying/cauterizing both fallopian tubes).

This is not necessarily true. We are now offering salpingectomies for sterilization as it leads to a theoretical decrease in ovarian cancer down the road.
posted by eglenner at 12:22 AM on May 10, 2016 [1 favorite]

Working in this field and scheduling these types of procedures, it sounds like you need to contact your physicians office who set up this procedure and find out exactly what codes they used. It sounds to be like this was coded incorrectly as a diagnostic procedure when clearly, it isn't.
posted by Sara_NOT_Sarah at 10:48 AM on May 11, 2016