Can an insurance co. change a routine colonoscopy to a diagnositic after the fact? (plan, hospital)
Please register to participate in our discussions with 2 million other members - it's free and quick! Some forums can only be seen by registered members. After you create your account, you'll be able to customize options and access all our 15,000 new posts/day with fewer ads.
In April I had my first ever colonoscopy. I'm 59 and healthy and there was no suspicion of cancer or any other problem. The benefits book provided by my insurance (bought in January thru the healthcare.gov site) states that it covers one routine colonoscopy every 10 years. I called the insurance company and they confirmed this. I am now being billed for an amount because the Dr. stated he found signs of diverticulitis while performing the routine screening colonoscopy. He also said that 90% of people my age will have the same finding of diverticulosis and is not something I need to worry about.
The insurance company says this gives them the right to go back in time and designate the procedure as "diagnostic" instead of "routine screening" and thus make me responsible out of pocket for the amount that they do not cover on diagnostic procedures. Is this legal on their part? It seems to me that if I am sent for a routine screening, then it is a routine screening no matter what the results. Isn't that the point of a routine screening? Does this mean that they can go back to any procedure I've ever had done and rebill at their whim?
In April I had my first ever colonoscopy. I'm 59 and healthy and there was no suspicion of cancer or any other problem. The benefits book provided by my insurance (bought in January thru the healthcare.gov site) states that it covers one routine colonoscopy every 10 years. I called the insurance company and they confirmed this. I am now being billed for an amount because the Dr. stated he found signs of diverticulitis while performing the routine screening colonoscopy. He also said that 90% of people my age will have the same finding of diverticulosis and is not something I need to worry about.
The insurance company says this gives them the right to go back in time and designate the procedure as "diagnostic" instead of "routine screening" and thus make me responsible out of pocket for the amount that they do not cover on diagnostic procedures. Is this legal on their part? It seems to me that if I am sent for a routine screening, then it is a routine screening no matter what the results. Isn't that the point of a routine screening? Does this mean that they can go back to any procedure I've ever had done and rebill at their whim?
Your doctor lied, diverticulitis isn't found in 90% of people your age. Has he offered you treatment?
One colonoscopy per 10 years isn't much. But in any case, it sounds like you should contact your state attorney general about the insurance company cooking the books in order to get out of paying part of the bill. Keep all records and correspondence with the ins. company. Keep a log of phone calls with them (date, what was discussed), and get the name of the ins. rep you talk to each time. It might come in handy.
File a complaint per their guidelines. It is clearly unfair. Notify the oversight agency and keep pressure on them. I would not waste your time on phone calls. Everything in writing. Time and date of your original phone call to them. cc the doctors office.
At this stage, I agree with AADAD. Better to put it in writing. Call insurance company and see who to write to and cc it to everyone. Also ask them to furnish you with where it says in your policy that should they find anything during the routine colonoscopy, they can go back in time and re-classify it. I can't get over what these insurance companies are doing. What crooks. I don't know if they should go behind Wall Street or in front of them anymore.
It seems everyone I know that is having their screening colonoscopies (and yes, the docs are saying almost everyone has a bit of diverticulitis in their 50's but most don't need treatment) is getting the first insurance explanation of benefits saying it's applied to their deductible and not covered.
They've had success just calling the insurance company, saying it's a screening and getting them paid 100%.
Insurance conspiracy? Maybe. We were told the only charge you would pay is if they had to do something extra, like snip polyps, but the colonoscopy would still be covered as preventative.
It seems everyone I know that is having their screening colonoscopies (and yes, the docs are saying almost everyone has a bit of diverticulitis in their 50's but most don't need treatment) is getting the first insurance explanation of benefits saying it's applied to their deductible and not covered.
They've had success just calling the insurance company, saying it's a screening and getting them paid 100%.
Insurance conspiracy? Maybe. We were told the only charge you would pay is if they had to do something extra, like snip polyps, but the colonoscopy would still be covered as preventative.
It's for profit. Denial of the initial claim probably saves them 10% right up front. Find out who the CEO and his top people are and blast email them. Hit em hard and hit em high is my wife's motto. It works!
So in the meantime, don't drink beer. I know, that is hard but diverticuli can be painful.
As someone who was diagnosed with diverticulosis in 2008, I have never heard of beer being a problem. That's news to me.
But I will say to the OP, you need to educate yourself about what you should and should not eat. Seeds and nuts in particular.
This past January my colon ruptured from a diverticulitis attack. I almost died from sepsis. The surgeon took out about the last 12 inches of my colon. A friend had an attack and almost bled to death.
This disease is nothing to mess around with, do your homework.
At this stage, I agree with AADAD. Better to put it in writing. Call insurance company and see who to write to and cc it to everyone. Also ask them to furnish you with where it says in your policy that should they find anything during the routine colonoscopy, they can go back in time and re-classify it. I can't get over what these insurance companies are doing. What crooks. I don't know if they should go behind Wall Street or in front of them anymore.
This will probably not come across the way it is intended, but as a doctor, I am glad insurance companies are finally ripping off patients the same way they have been treating doctors for years. Only when patients have skin in the game will the insurance companies have a reason to shape up. When I complain to an insurance company on behalf of a patient, they don't care because I am not the customer....the patient is the customer since they (or their employer) pay the premiums. To the original poster.....scream loud and often at the insurance company. They will probably blame it on the doctor's office at some point, saying the doctor didn't follow their rules.....which change on a whim and no office can keep up with all the different rules for each plan.
This will probably not come across the way it is intended, but as a doctor, I am glad insurance companies are finally ripping off patients the same way they have been treating doctors for years. Only when patients have skin in the game will the insurance companies have a reason to shape up. When I complain to an insurance company on behalf of a patient, they don't care because I am not the customer....the patient is the customer since they (or their employer) pay the premiums. To the original poster.....scream loud and often at the insurance company. They will probably blame it on the doctor's office at some point, saying the doctor didn't follow their rules.....which change on a whim and no office can keep up with all the different rules for each plan.
I agree and have been saying so for ages it seems. As long as the customer (patient) remains insulated to costs, continued abuse by insurance companies and sometimes hospitals will continue. Nothing gets your attention faster than when it hits your own pocketbook.
Please register to post and access all features of our very popular forum. It is free and quick. Over $68,000 in prizes has already been given out to active posters on our forum. Additional giveaways are planned.
Detailed information about all U.S. cities, counties, and zip codes on our site: City-data.com.
Please register to participate in our discussions with 2 million other members - it's free and quick! Some forums can only be seen by registered members. After you create your account, you'll be able to customize options and access all our 15,000 new posts/day with fewer ads.
