Will I Win This Appeal? (medical, doctor, claim, patient)

[piperdiva]

I recently moved to a new area. My new GP referred me to a local rheumatologist to treat my fibromyalgia, as I was under the care of one for 12 years in my old area. I called the rheumy office, told them I had fibro, and made the appointment. Once I arrived, I filled out the usual new patient paperwork. Fine so far....

I see the doctor, and she flat out informed me that she doesn't treat fibromyalgia, and looking at my paperwork, doesn't understand the rx protocoll my doctor put me on, and since 2 of the meds are SSRI's, I need to see a shrink! She then said my drug cocktail was dangerous, and she was worried "something might happen." I calmly explained to her that none of my meds are opiods and addictive, but she ignored that and said she could only write an RX for Ultram . She gave me a prescription (I did not fill it) and the name of a shrink (I did not call) and left. NOW, her office bills the insurance for $404.00 code CPT 99204. Which means she billed me as a new patient given 45 minutes of specialized care. I was there for about a half hour while she told me why she only treats real things like lupus, yada yada. I called the insurance company, they told me to appeal

[Flamingo13]

You saw the doctor - there is nothing to appeal (just because you didn't like what you were told!) - it's on you to research an appropriate doctor.

[convextech]

Originally Posted by piperdiva

I see the doctor...she billed me as a new patient

You saw the doctor and you were a new patient; you just didn't like what she said. There is nothing to appeal.

Go to another doctor who suits your needs.

[piperdiva]

Unfortunately, I had to use her because of my insurance (in net work only doctors), so I was stuck. Needless to say I will be changing insurance next year.

[Rabrrita]

You may have a valid appeal based on the provider lying to you about the services they provided. However, the key will be what you told the provider when setting the appointment. Did you say you are seeking treatment of your specific condition or did you just say you have a certain condition? You also harmed your position by staying once told they don't service your condition. By remaining and discussing the medications, you accepted professional services.

But, what are you appealing? Is it some co-pay or co-insurance? is it the bill in it's entirety to the insurance company even if you have no cost to you? Are you claiming fraud?

[Angie682]

You are not likely to win your appeal. You were a new patient and she rendered a service to you. She is entitled to be reimbursed for her services. Her office coded the claim correctly per CPT guidelines.

You were not happy with her advice which is not an appealable issue.

I am an appeals supervisor at a major insurance company with 30 years of experience.

[piperdiva]

Angie, I understand what you are saying, but when I made the appointment I asked if she treats fibromyalgia and the office person said yes. Also, perhaps I should have been more detailed, but she discussed my rx protocol and THEN said she will not take me as a patient. Is this still under the code guidelines? What type of scenario would not meet the criteria?

[Flamingo13]

You made an appt. to see a Dr., she saw you - she apparently doesn't believe in treating Fibro. the way you want it to be treated - that means Dr. shopping.

[Moonpie504]

She billed your insurance for $404, is that how much you're out or are you saying that she shouldn't be paid at all?

[Angie682]

Originally Posted by piperdiva

Angie, I understand what you are saying, but when I made the appointment I asked if she treats fibromyalgia and the office person said yes. Also, perhaps I should have been more detailed, but she discussed my rx protocol and THEN said she will not take me as a patient. Is this still under the code guidelines? What type of scenario would not meet the criteria?

Here's the thing-- your doctor referred you to her office and you called to make the appointment. If you called her office and said my GP's office referred me to your office, the receptionist might not have caught the part about you were specifically wanting to be treated for fibromyalgia. Did you specifically state I only want to make an appointment if you specialize in treating fibromyalgia?

Honestly, I think that the new doctor was worried about the meds you are on currently. Had you not been on that regimen she might have treated you for fibromyalgia using a more standard protocol . If the doctor said the regimen you are currently on is dangerous, I would be very concerned about that and maybe explore that further. She did not want to continue presribing that regimen due to liability issues. You indicated you had no interest in changing your regimen.

It sounds like overall it was just not a good fit for either of you.

She did meet with you, went through your medical and RX history (which sounds rather complex), notified you your current regimen is not standard of care and potentially dangerous, and prescribed you a medication which you did not fill. There is nothing that supports your insurance not paying for her services or you not paying your copayment or coinsurance.

You might want to seek out a provider that specializes in treating fibromyalgia. Good luck!