How to contest a bogus insurance claim submitted by doctor?
March 2, 2019 11:31 AM Subscribe
New health insurance company approved an overtly bogus claim by my doctor related to what I expected to be a free annual exam. As a result, I was billed over $200 (with unauthorized extra blood tests, almost $400). I appealed the decision, had my appeal rejected, am now rebutting the appeal with insurance company, doctor's billing service, and state insurance commissioner.
What else can I do to fight this bullshit?
I saw a new doctor for the first time last August under a new insurance plan I started last year. When I made the appointment with the doctor's office, I made it clear that I wanted this to be the free annual exam provided by my insurance plan. I intended to use the exam to evaluate the doctor and decide whether to keep him as my primary physician.
During the exam, I mentioned that I had been feeling a strain in my abdomen. I very clearly stated that there was no pain. The doctor did not examine my abdomen but recommended an appointment for a colonoscopy which he noted they could perform there in his office. It was about that point that I decided I would not be returning to this office.
A few weeks after the exam I received two bills: one from a blood lab for about $150 in blood tests. And one from the doctor's office for about $200. I challenged the claim with my insurance company but they defended it stating that, because I had mentioned my abdomen, the exam was no longer "preventative" but "medical" and therefore not free under the policy (first time I encountered these terms). I've never gotten any explanation for the additional blood tests I didn't authorize.
Here's the best part. To justify its ruling, the insurance company cited two diagnostic code submitted by the doctor (this was the first I heard of them):
Suffice to say I'm furious. It's not the money so much. That's covered by the HSA my company contributes to. It's the systemic corruption (I marvel at the pettiness of it in this case) and the sense of futility (I haven't even bothered trying to see another doctor since this.) If I have to go through this with a routine annual physical, I can only imagine (and, well, occasionally read about here on MeFi) the kind of shit people with serious medical issues go through.
I received the appeal decision a couple weeks ago. I have sent a letter pointing out errors in the appeal decision to BCBSM (you have to mail them a letter), DIFS, and the doctor's billing service (they are threatening to send me to collections). Is there anything else I should be doing?
I saw a new doctor for the first time last August under a new insurance plan I started last year. When I made the appointment with the doctor's office, I made it clear that I wanted this to be the free annual exam provided by my insurance plan. I intended to use the exam to evaluate the doctor and decide whether to keep him as my primary physician.
During the exam, I mentioned that I had been feeling a strain in my abdomen. I very clearly stated that there was no pain. The doctor did not examine my abdomen but recommended an appointment for a colonoscopy which he noted they could perform there in his office. It was about that point that I decided I would not be returning to this office.
A few weeks after the exam I received two bills: one from a blood lab for about $150 in blood tests. And one from the doctor's office for about $200. I challenged the claim with my insurance company but they defended it stating that, because I had mentioned my abdomen, the exam was no longer "preventative" but "medical" and therefore not free under the policy (first time I encountered these terms). I've never gotten any explanation for the additional blood tests I didn't authorize.
Here's the best part. To justify its ruling, the insurance company cited two diagnostic code submitted by the doctor (this was the first I heard of them):
- R10.0: acute abdominal pain
- K57.30: diverticulosis of large intestine without tear or abscess without bleeding
Suffice to say I'm furious. It's not the money so much. That's covered by the HSA my company contributes to. It's the systemic corruption (I marvel at the pettiness of it in this case) and the sense of futility (I haven't even bothered trying to see another doctor since this.) If I have to go through this with a routine annual physical, I can only imagine (and, well, occasionally read about here on MeFi) the kind of shit people with serious medical issues go through.
I received the appeal decision a couple weeks ago. I have sent a letter pointing out errors in the appeal decision to BCBSM (you have to mail them a letter), DIFS, and the doctor's billing service (they are threatening to send me to collections). Is there anything else I should be doing?
Best answer: I would write a polite letter to the provider in question informing him that "upcoding" , or submitting a claim for a more expensive procedure than was performed, seems like an ethical violation and you are reporting him to the appropriate licensing board and their ethics committee.
I would also file that complaint.
posted by OHenryPacey at 11:51 AM on March 2, 2019 [21 favorites]
I would also file that complaint.
posted by OHenryPacey at 11:51 AM on March 2, 2019 [21 favorites]
Have you spoken with the doctor’s office and asked them to resubmit the claim as an annual physical?
posted by something something at 12:07 PM on March 2, 2019 [4 favorites]
posted by something something at 12:07 PM on March 2, 2019 [4 favorites]
Instead of appealing, can you go the fraud route or do both at the same time? It's usually a different department so you may have better luck. I know medicare has a hotline, but I don't know about your specific insurance.
posted by AlexiaSky at 12:33 PM on March 2, 2019
posted by AlexiaSky at 12:33 PM on March 2, 2019
I've never gotten any explanation for the additional blood tests I didn't authorize.
Can you clarify this? If you didn't authorize a test, did you let them draw a sample? Or do you mean they performed extra diagnostics on the sample without your acknowledgment? What was the blood supposed to be drawn for?
It seems like you have a much clearer case to pursue if they're billing you for a test that never happened.
posted by JoeZydeco at 12:33 PM on March 2, 2019 [4 favorites]
Can you clarify this? If you didn't authorize a test, did you let them draw a sample? Or do you mean they performed extra diagnostics on the sample without your acknowledgment? What was the blood supposed to be drawn for?
It seems like you have a much clearer case to pursue if they're billing you for a test that never happened.
posted by JoeZydeco at 12:33 PM on March 2, 2019 [4 favorites]
I solved a $1000+ medical billing problem last year by leaving a 1-star Yelp review. When the office contacted me and only sorta wanted to help, but not in any way that would substantially lower my bill, I updated my review to further articulate my negative experience. THEN they substantively helped me and removed the charge.
posted by BlahLaLa at 2:22 PM on March 2, 2019 [6 favorites]
posted by BlahLaLa at 2:22 PM on March 2, 2019 [6 favorites]
something something is right. The doctor's office needs to submit a corrected claim with the code for annual physical as the first diagnosis on the claim. The doctor's office also needs to contact the laboratory and ask them to do the same.
posted by txtwinkletoes at 2:27 PM on March 2, 2019 [1 favorite]
posted by txtwinkletoes at 2:27 PM on March 2, 2019 [1 favorite]
Response by poster: Thanks for all the responses. To follow up on a few:
I wound up suing the insurance company in small claims court, bringing a RICO claim for triple damages. We settled for 1.5 times damages.
@exogenous Do you think there'd be any benefit in involving a lawyer? Say I gave myself $1000 legal budget, could I expect to find a lawyer who could help serve a just an end or is it more a case of now I have 2 problems? If so, any recommendations for finding a lawyer?
I would write a polite letter to the provider in question informing him that "upcoding" , or submitting a claim for a more expensive procedure than was performed, seems like an ethical violation and you are reporting him to the appropriate licensing board and their ethics committee.
@OHenryPacey Thanks for the link! I've bookmarked it. I've put off going to the medical board in hopes of better understanding a little more about the process and how best to present my complaint.
In speaking with the doctor's billing office, I have stated that if the misdiagnosis was not corrected, I would consider my responsibility to report the case to state medical board.
Have you spoken with the doctor’s office and asked them to resubmit the claim as an annual physical?
@something_something In making the appointment, I was unambiguous about intending this to be my annual free exam. From my appeal letter:
Since I had never visited this doctor’s office before, I planned to use the free annual exam provided under my insurance plan to evaluate the doctor and his office. When I called to schedule the appointment with Dr. X’s office, the staff member with whom I spoke on the phone informed me that I would have to pay with cash or check. I was confused by this so I made it clear to her that I wished to take advantage of the free annual exam.
The assistant said she would need to double check the cost. I provided my insurance information and she told me that the visit would be free. If she had not, I would not have made the appointment since I have an HSA card that I use for payment and find the idea of carrying a wad of cash into a doctor’s office for an ordinary medical exam a bit ludicrous and unseemly.
In every communication with both the doctor's billing office and the insurance, I've concluded by requesting that they work together to correct the invalid claim codes.
Instead of appealing, can you go the fraud route or do both at the same time? It's usually a different department so you may have better luck. I know medicare has a hotline, but I don't know about your specific insurance.
@AlexiaSky I've considered that. I came across a page on the insurer's website but I'm not sure what the threshold is for fraud. I figured when I presented the facts to the insurance company, they might be motivated to investigate that themselves. Apparently not.
What is also interesting is I got the impression after visiting the doctor that a significant portion of is business is senior citizens, probably on medicare, which I suppose might explain the reckless confidence with which he upcoded my diagnosis.
I have this New Yorker article I read recently in mind:
https://www.newyorker.com/magazine/2019/02/04/the-personal-toll-of-whistle-blowing
Can you clarify this? If you didn't authorize a test, did you let them draw a sample? Or do you mean they performed extra diagnostics on the sample without your acknowledgment? What was the blood supposed to be drawn for?
@JoeZydeco Yes, the latter, the extra diagnostics. Before the blood tests, a nurse administered an EKG. Before she did so, I explicitly asked her if I would be billed. She said, "No, I don't think so." Again from my letter:
After Dr. X concluded his visit with me, a nurse came to my room to administer the electrocardiogram. I was not expecting this and saw no need for it as I exercise regularly, eat well, and have no history of heart disease in my family. I asked the nurse if there would be any charge for it. She said no so I let her proceed, mostly to be a good sport and not come off as a total crank. She struggled to attach the contact to my legs and chest properly and required a more experienced nurse to assist her. They both seemed to have trouble operating the machine recording the measurements. The procedure felt like a waste of 15 minutes or so of everyone’s time. I never received the results of this test but even if I had I wouldn’t have put any faith in their validity.
I guess the lesson here is: be an obnoxious jerk before you let a medical professional do anything. I imagine they love that. My previous experience was with Kaiser where I faced none of these shenanigans.
posted by bunbury at 2:30 PM on March 2, 2019 [2 favorites]
I wound up suing the insurance company in small claims court, bringing a RICO claim for triple damages. We settled for 1.5 times damages.
@exogenous Do you think there'd be any benefit in involving a lawyer? Say I gave myself $1000 legal budget, could I expect to find a lawyer who could help serve a just an end or is it more a case of now I have 2 problems? If so, any recommendations for finding a lawyer?
I would write a polite letter to the provider in question informing him that "upcoding" , or submitting a claim for a more expensive procedure than was performed, seems like an ethical violation and you are reporting him to the appropriate licensing board and their ethics committee.
@OHenryPacey Thanks for the link! I've bookmarked it. I've put off going to the medical board in hopes of better understanding a little more about the process and how best to present my complaint.
In speaking with the doctor's billing office, I have stated that if the misdiagnosis was not corrected, I would consider my responsibility to report the case to state medical board.
Have you spoken with the doctor’s office and asked them to resubmit the claim as an annual physical?
@something_something In making the appointment, I was unambiguous about intending this to be my annual free exam. From my appeal letter:
Since I had never visited this doctor’s office before, I planned to use the free annual exam provided under my insurance plan to evaluate the doctor and his office. When I called to schedule the appointment with Dr. X’s office, the staff member with whom I spoke on the phone informed me that I would have to pay with cash or check. I was confused by this so I made it clear to her that I wished to take advantage of the free annual exam.
The assistant said she would need to double check the cost. I provided my insurance information and she told me that the visit would be free. If she had not, I would not have made the appointment since I have an HSA card that I use for payment and find the idea of carrying a wad of cash into a doctor’s office for an ordinary medical exam a bit ludicrous and unseemly.
In every communication with both the doctor's billing office and the insurance, I've concluded by requesting that they work together to correct the invalid claim codes.
Instead of appealing, can you go the fraud route or do both at the same time? It's usually a different department so you may have better luck. I know medicare has a hotline, but I don't know about your specific insurance.
@AlexiaSky I've considered that. I came across a page on the insurer's website but I'm not sure what the threshold is for fraud. I figured when I presented the facts to the insurance company, they might be motivated to investigate that themselves. Apparently not.
What is also interesting is I got the impression after visiting the doctor that a significant portion of is business is senior citizens, probably on medicare, which I suppose might explain the reckless confidence with which he upcoded my diagnosis.
I have this New Yorker article I read recently in mind:
https://www.newyorker.com/magazine/2019/02/04/the-personal-toll-of-whistle-blowing
Can you clarify this? If you didn't authorize a test, did you let them draw a sample? Or do you mean they performed extra diagnostics on the sample without your acknowledgment? What was the blood supposed to be drawn for?
@JoeZydeco Yes, the latter, the extra diagnostics. Before the blood tests, a nurse administered an EKG. Before she did so, I explicitly asked her if I would be billed. She said, "No, I don't think so." Again from my letter:
After Dr. X concluded his visit with me, a nurse came to my room to administer the electrocardiogram. I was not expecting this and saw no need for it as I exercise regularly, eat well, and have no history of heart disease in my family. I asked the nurse if there would be any charge for it. She said no so I let her proceed, mostly to be a good sport and not come off as a total crank. She struggled to attach the contact to my legs and chest properly and required a more experienced nurse to assist her. They both seemed to have trouble operating the machine recording the measurements. The procedure felt like a waste of 15 minutes or so of everyone’s time. I never received the results of this test but even if I had I wouldn’t have put any faith in their validity.
I guess the lesson here is: be an obnoxious jerk before you let a medical professional do anything. I imagine they love that. My previous experience was with Kaiser where I faced none of these shenanigans.
posted by bunbury at 2:30 PM on March 2, 2019 [2 favorites]
This happened to me, and the issue is that a diagnosis code was submitted, which superseded a code for an annual visit, (which would not be billed for). In my case I had an annual GYN but mentioned a symptom, which then triggered the visit to change to a visit that triggered a co-pay. I had to pay it, because we had addressed the symptom I brought up.
Lab tests, whether in conjunction with an annual visit or a "sick visit" would be billed for, and should be submitted to insurance. Without knowing what the tests are, it's hard to speculate, but I'd guess they included cholesterol, basic chemistry and CBC. That would add up to about $200 in my area and would be absolutely the minimum baseline annual blood tests I'd expect a new doc to perform. It's the doctor's fee that is covered by a no-cost annual visit, not labs, Xrays, etc. Quest or whatever lab was used will not process specimens without payment.
Unfortunately, I think the insurance company has you here. You mentioned a symptom and the doctor coded for it. You didn't realize it, but the visit changed into a visit that required a diagnostic code other than "annual exam". Expecting the doctor to omit a code for a problem he considered, and which you brought to his attention, would itself be insurance fraud. Perhaps he should have mentioned that considering your abdominal symptom would change the coding and the charge, but on the other hand how reasonable is it to expect a doctor to ignore a symptom the patient himself brought up? And a lack of pain does not mean something serious is not going on. Lots of tumors, for example, are not painful. Lack of pain is not definitive in and of itself, and if you do have diverticulitis, you need to know about it. There are important interventions you can make to reduce its impact. I encourage you to follow up about it with a GI doctor of your choice.
posted by citygirl at 2:33 PM on March 2, 2019 [9 favorites]
Lab tests, whether in conjunction with an annual visit or a "sick visit" would be billed for, and should be submitted to insurance. Without knowing what the tests are, it's hard to speculate, but I'd guess they included cholesterol, basic chemistry and CBC. That would add up to about $200 in my area and would be absolutely the minimum baseline annual blood tests I'd expect a new doc to perform. It's the doctor's fee that is covered by a no-cost annual visit, not labs, Xrays, etc. Quest or whatever lab was used will not process specimens without payment.
Unfortunately, I think the insurance company has you here. You mentioned a symptom and the doctor coded for it. You didn't realize it, but the visit changed into a visit that required a diagnostic code other than "annual exam". Expecting the doctor to omit a code for a problem he considered, and which you brought to his attention, would itself be insurance fraud. Perhaps he should have mentioned that considering your abdominal symptom would change the coding and the charge, but on the other hand how reasonable is it to expect a doctor to ignore a symptom the patient himself brought up? And a lack of pain does not mean something serious is not going on. Lots of tumors, for example, are not painful. Lack of pain is not definitive in and of itself, and if you do have diverticulitis, you need to know about it. There are important interventions you can make to reduce its impact. I encourage you to follow up about it with a GI doctor of your choice.
posted by citygirl at 2:33 PM on March 2, 2019 [9 favorites]
Response by poster: I solved a $1000+ medical billing problem last year by leaving a 1-star Yelp review.
@BlahLaLa Don't have an active Yelp account so I expect my review would be invisible if I created a new one. Also, were you not concerned about SLAPP action by the doctor?
Unfortunately, I think the insurance company has you here. You mentioned a symptom and the doctor coded for it. You didn't realize it, but the visit changed into a visit that required a diagnostic code other than "annual exam".
@citygirl The problem is, as far as I can tell, the doctor pulled that diverticulosis diagnosis out of his ass to justify upbilling me for additional tests. What evidence I gave him, he blatantly misrepresented. You see no problem there?
As to me not understanding that free medical exams are those in which you say nothing other than you're feeling great, [blinks]. I mean I've figured that out by now. But step back for a moment and reflect on that. What's the point of even offering a free annual exam if the wrong word is going to cost you a fee that can be dictated at the doctor's whim? It defies common sense.
posted by bunbury at 2:51 PM on March 2, 2019 [4 favorites]
@BlahLaLa Don't have an active Yelp account so I expect my review would be invisible if I created a new one. Also, were you not concerned about SLAPP action by the doctor?
Unfortunately, I think the insurance company has you here. You mentioned a symptom and the doctor coded for it. You didn't realize it, but the visit changed into a visit that required a diagnostic code other than "annual exam".
@citygirl The problem is, as far as I can tell, the doctor pulled that diverticulosis diagnosis out of his ass to justify upbilling me for additional tests. What evidence I gave him, he blatantly misrepresented. You see no problem there?
As to me not understanding that free medical exams are those in which you say nothing other than you're feeling great, [blinks]. I mean I've figured that out by now. But step back for a moment and reflect on that. What's the point of even offering a free annual exam if the wrong word is going to cost you a fee that can be dictated at the doctor's whim? It defies common sense.
posted by bunbury at 2:51 PM on March 2, 2019 [4 favorites]
Why do you think the doctor "pulled the diverculosis diagnoses out of his ass"? Perhaps you do, in fact, have symptoms a reasonable physician would consider under a differential diagnosis for diverticulosis. This is a potentially serious diagnosis that can be mild or very problematic, even crippling.
I take your point about the issue of an annual exam that doesn't allow for a concurrent issue being included, but that's the devilish detail that ICD 10 coding causes. That seems more of a policy issue, as you note, and should be considered by policy makers, but it's difficult to reconcile negatives (annual exam, no problems discussed) with positive (symptom, problem discussed), and figure out how to charge fairly to cover both situations.
posted by citygirl at 3:37 PM on March 2, 2019 [1 favorite]
I take your point about the issue of an annual exam that doesn't allow for a concurrent issue being included, but that's the devilish detail that ICD 10 coding causes. That seems more of a policy issue, as you note, and should be considered by policy makers, but it's difficult to reconcile negatives (annual exam, no problems discussed) with positive (symptom, problem discussed), and figure out how to charge fairly to cover both situations.
posted by citygirl at 3:37 PM on March 2, 2019 [1 favorite]
Response by poster: Why do you think the doctor "pulled the diverculosis diagnoses out of his ass"?
@citygirl Yeah, sorry, I guess I didn't explain that in my account here. I went into more detail in my letter to the insurance company:
During the examination, in response to an inquiry regarding my health by Dr. X, I informed him I had been experiencing some discomfort in the area of my left abdomen. He asked me if it was painful. I explicitly told him it was not painful. I was unequivocal on this point as I did not want it to be misdiagnosed as something more severe than it was. I told him that it felt like a mild strain. I pointed to the area where I felt the strain. He never examined the area directly.
This is the first I’ve heard of the diagnosis of “diverticulosis of large intestine without tear or abscess without bleed.” On what basis did he arrive at that diagnosis? Did BCBSM’s Associate Medical Director verify the medical basis of this diagnosis?
Dr. X did not offer any sort of diagnosis to me during the visit. He spent most our time together repeating questions that I had answered already on the form I had filled out in the waiting room and scribbling down codes on a form in his lap. He recommended a colonoscopy and referred me for an ultrasound. I declined the colonoscopy despite some pressure from his front-office staff to sign a document authorizing it as I checked out. I never scheduled the ultrasound.
You showed more curiosity about my actual symptoms in your comment than he did during the exam. And you came up with a different diagnosis: "And a lack of pain does not mean something serious is not going on. Lots of tumors, for example, are not painful." Why didn't he code it for a tumor? Is diverticulosis acutely painful? Why did he code acute pain in the first place? Did he mistake "strain" for "pain"? Did he mistake "mild" for "acute"?
For $300 (all said and done), I think he could have at least mentioned the diagnosis he seems to have formed there on the spot. When he recommended a colonoscopy and an ultrasound without the merest explanation, I figured maybe he just didn't want to speculate without a little more evidence. I also began to suspect that he was, as Gawande described them in his McAllen New Yorker article, one of those physicians "who see their practice primarily as a revenue stream."
Regarding "the issue of an annual exam that doesn't allow for a concurrent issue being included", is this common knowledge? I only learned this after this visit. (No idea what ICD 10 means -- some kind of coding standard?) I'm not an industry insider, but I've kept up with the policy debates going back to Hillarycare. And I've had a least a couple exams over the last few years where I mentioned minor ailments and have never got bitten by this. The fact that some people treat this as a fact of life, and yet still don't see it as a symbol of everything wrong with our system, just puzzles me.
posted by bunbury at 4:20 PM on March 2, 2019 [1 favorite]
@citygirl Yeah, sorry, I guess I didn't explain that in my account here. I went into more detail in my letter to the insurance company:
During the examination, in response to an inquiry regarding my health by Dr. X, I informed him I had been experiencing some discomfort in the area of my left abdomen. He asked me if it was painful. I explicitly told him it was not painful. I was unequivocal on this point as I did not want it to be misdiagnosed as something more severe than it was. I told him that it felt like a mild strain. I pointed to the area where I felt the strain. He never examined the area directly.
This is the first I’ve heard of the diagnosis of “diverticulosis of large intestine without tear or abscess without bleed.” On what basis did he arrive at that diagnosis? Did BCBSM’s Associate Medical Director verify the medical basis of this diagnosis?
Dr. X did not offer any sort of diagnosis to me during the visit. He spent most our time together repeating questions that I had answered already on the form I had filled out in the waiting room and scribbling down codes on a form in his lap. He recommended a colonoscopy and referred me for an ultrasound. I declined the colonoscopy despite some pressure from his front-office staff to sign a document authorizing it as I checked out. I never scheduled the ultrasound.
You showed more curiosity about my actual symptoms in your comment than he did during the exam. And you came up with a different diagnosis: "And a lack of pain does not mean something serious is not going on. Lots of tumors, for example, are not painful." Why didn't he code it for a tumor? Is diverticulosis acutely painful? Why did he code acute pain in the first place? Did he mistake "strain" for "pain"? Did he mistake "mild" for "acute"?
For $300 (all said and done), I think he could have at least mentioned the diagnosis he seems to have formed there on the spot. When he recommended a colonoscopy and an ultrasound without the merest explanation, I figured maybe he just didn't want to speculate without a little more evidence. I also began to suspect that he was, as Gawande described them in his McAllen New Yorker article, one of those physicians "who see their practice primarily as a revenue stream."
Regarding "the issue of an annual exam that doesn't allow for a concurrent issue being included", is this common knowledge? I only learned this after this visit. (No idea what ICD 10 means -- some kind of coding standard?) I'm not an industry insider, but I've kept up with the policy debates going back to Hillarycare. And I've had a least a couple exams over the last few years where I mentioned minor ailments and have never got bitten by this. The fact that some people treat this as a fact of life, and yet still don't see it as a symbol of everything wrong with our system, just puzzles me.
posted by bunbury at 4:20 PM on March 2, 2019 [1 favorite]
Mod note: Hey bunbury, you don't need to respond to every comment; I think people have enough clarification now to provide answers.
posted by Eyebrows McGee (staff) at 4:46 PM on March 2, 2019 [2 favorites]
posted by Eyebrows McGee (staff) at 4:46 PM on March 2, 2019 [2 favorites]
ICD 10 is the bible of medical billing. Nothing is billed for without an ICD 10 code, also called a procedure code. Should be on your insurance bills or the EOB (Explanation of benefits) they send you, and they are easy to Google.
posted by citygirl at 7:11 PM on March 2, 2019 [1 favorite]
posted by citygirl at 7:11 PM on March 2, 2019 [1 favorite]
ICD-10 codes are the only thing insurance recognizes. They are the "pics or it didn't happen" of medicine. They are also famously bizarre; "struck by a duck, subsequent encounter" has its own code, but there is no code for "mild non-painful abdominal discomfort or strain." You can verify this for yourself with Google. Welcome to the Kakfaesque world of modern medicine. We do very much see this as a broken system and many of us are working to fix it.
The doctor probably typed "abdomen" into whatever electronic medical record he has and picked whatever seemed closest to your symptoms. The only way you're going to fix this is to ask him to change the code to a preventative visit code (they all start with V). This may or may not be successful, but yelling at your insurance ain't gonna do diddly squat because as far as they know, you have an acute abdomen secondary to diverticulitis.
(Ironically, depending on your age/medical history, the colonoscopy and ultrasound may have been 100% covered as preventative, as screens for colon cancer and aortic aneurysm, respectively. But only if coded as preventative, not symptomatic / diagnostic.)
posted by basalganglia at 1:23 AM on March 3, 2019 [2 favorites]
The doctor probably typed "abdomen" into whatever electronic medical record he has and picked whatever seemed closest to your symptoms. The only way you're going to fix this is to ask him to change the code to a preventative visit code (they all start with V). This may or may not be successful, but yelling at your insurance ain't gonna do diddly squat because as far as they know, you have an acute abdomen secondary to diverticulitis.
(Ironically, depending on your age/medical history, the colonoscopy and ultrasound may have been 100% covered as preventative, as screens for colon cancer and aortic aneurysm, respectively. But only if coded as preventative, not symptomatic / diagnostic.)
posted by basalganglia at 1:23 AM on March 3, 2019 [2 favorites]
...find the idea of carrying a wad of cash into a doctor’s office for an ordinary medical exam a bit ludicrous and unseemly...
...I let her proceed, mostly to be a good sport and not come off as a total crank. She struggled to attach the contact to my legs and chest properly and required a more experienced nurse to assist her. They both seemed to have trouble operating the machine recording the measurements. The procedure felt like a waste of 15 minutes or so of everyone’s time. I never received the results of this test but even if I had I wouldn’t have put any faith in their validity...
Your frustration is 100% justified, but going forward you need to remove this sort of commentary from your communications with insurance/billing/regulators on this matter. Communications should be strictly factual and delivered in a neutral tone. Otherwise you risk coming off as a crackpot and getting nowhere with the folks reading your letters. Neither of these "details" are actually relevant to your issues.
posted by schroedingersgirl at 5:10 AM on March 3, 2019 [13 favorites]
...I let her proceed, mostly to be a good sport and not come off as a total crank. She struggled to attach the contact to my legs and chest properly and required a more experienced nurse to assist her. They both seemed to have trouble operating the machine recording the measurements. The procedure felt like a waste of 15 minutes or so of everyone’s time. I never received the results of this test but even if I had I wouldn’t have put any faith in their validity...
Your frustration is 100% justified, but going forward you need to remove this sort of commentary from your communications with insurance/billing/regulators on this matter. Communications should be strictly factual and delivered in a neutral tone. Otherwise you risk coming off as a crackpot and getting nowhere with the folks reading your letters. Neither of these "details" are actually relevant to your issues.
posted by schroedingersgirl at 5:10 AM on March 3, 2019 [13 favorites]
ICD-10 is used to provide the diagnosis codes. The procedures themselves are billed with procedure codes from the CPT code set (ICD-10 Procedure codes only being used for the facility portion of inpatient visits). If the ICD-10 Diagnosis code doesn't justify the CPT procedure code, claims are denied for lack of medical necessity.
Based on your description, the diagnosis codes assigned might not be valid, but an audit of the diagnosis codes depends on the report written by the physician. So if you want to dispute the diverticulosis or abdominal pain diagnosis codes, you need to request a copy of your medical records for that visit. If there is no mention of diverticulosis or abdominal pain in the record, you forward that to your insurance company and say that the physician submitted a diagnosis code that isn't reflected in the medical record. Which, if you get your way, causes them to review the record themselves. Best (or worst depending on your point of view) case, they decide there is no medical necessity for the procedure performs, claw back their insurance payments... and the doctor bills you for services rendered.
To dispute the procedure codes themselves, you need to be able to prove that the work wasn't performed. Which could be difficult since the lab work sounds like it was done and the doctor actually did evaluate your abdominal strain.
posted by Apoch at 7:04 AM on March 3, 2019
Based on your description, the diagnosis codes assigned might not be valid, but an audit of the diagnosis codes depends on the report written by the physician. So if you want to dispute the diverticulosis or abdominal pain diagnosis codes, you need to request a copy of your medical records for that visit. If there is no mention of diverticulosis or abdominal pain in the record, you forward that to your insurance company and say that the physician submitted a diagnosis code that isn't reflected in the medical record. Which, if you get your way, causes them to review the record themselves. Best (or worst depending on your point of view) case, they decide there is no medical necessity for the procedure performs, claw back their insurance payments... and the doctor bills you for services rendered.
To dispute the procedure codes themselves, you need to be able to prove that the work wasn't performed. Which could be difficult since the lab work sounds like it was done and the doctor actually did evaluate your abdominal strain.
posted by Apoch at 7:04 AM on March 3, 2019
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A person in your situation should be aware of the statute of limitations. This is not legal advice and I am not your lawyer.
posted by exogenous at 11:41 AM on March 2, 2019 [3 favorites]