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In December I went to my regular doctor for knee pain and swelling. He took x-rays and determined I had a bone spur. He gave me a cortisone shot and some anti-inflammatory drugs I felt better almost immediately.
About a month later I had the same problem, unfortunately the pain got really bad on a Friday night so I had to go to an urgent care facility. I told the doctor about the bone spur I had recently had. He did not take any x-rays or blood. He did mention in passing that was not positive it was a bone spur, could possibly be gout, but treatment would be the same so it didn't matter. He drained my knee and gave me another shot.I have had gout before, and I have exclusion on my insurance for gout. I did not mention or even think about my insurance exclusion
I had not reached my deductible for my insurance so I paid my full bill (insurance negotiated rate) of about $140. Now I've got an addition bill for $180. I found out when they submitted the paperwork they listed gout as a possible cause and my insurance denied the claim.
I have no problem paying what I owe, and to avoid having it go to collections I will probably pay anyway, but the fact the doctors office was happy making a negotiated rate of $140 before they knew my insurance would deny the claim. Now they are trying more than double what they would have made.
In December I went to my regular doctor for knee pain and swelling. He took x-rays and determined I had a bone spur. He gave me a cortisone shot and some anti-inflammatory drugs I felt better almost immediately.
About a month later I had the same problem, unfortunately the pain got really bad on a Friday night so I had to go to an urgent care facility. I told the doctor about the bone spur I had recently had. He did not take any x-rays or blood. He did mention in passing that was not positive it was a bone spur, could possibly be gout, but treatment would be the same so it didn't matter. He drained my knee and gave me another shot.I have had gout before, and I have exclusion on my insurance for gout. I did not mention or even think about my insurance exclusion
I had not reached my deductible for my insurance so I paid my full bill (insurance negotiated rate) of about $140. Now I've got an addition bill for $180. I found out when they submitted the paperwork they listed gout as a possible cause and my insurance denied the claim.
I have no problem paying what I owe, and to avoid having it go to collections I will probably pay anyway, but the fact the doctors office was happy making a negotiated rate of $140 before they knew my insurance would deny the claim. Now they are trying more than double what they would have made.
Since the doctor mentioned gout and your insurance has an exclusion for gout --- and you knew it --- you owe the additional charge. Pay up.
Maybe, but if I would have known I would be charged $180 extra for the same service, and I was 99% sure it was not gout, I would have asked for a blood test to rule gout out.
I had not reached my insurance deductible for the year, and the doctors office knew that, so I paid my bill in full at the time of service ($140). The doctors office was not expecting any additional payment from me or my insurance company due to the per-existing negotiated rates. When they turned my bill into my insurance company and the claim was denied I got billed for an extra $180($320 total). The denial of the claim freed the doctors office to charge whatever rate they wanted.
I have a gout exclusion because I have had gout a few times in the past, but I am now on Allopurinol and have not had an attack since I started taking that drug.
I had not reached my insurance deductible for the year, and the doctors office knew that, so I paid my bill in full at the time of service ($140). The doctors office was not expecting any additional payment from me or my insurance company due to the per-existing negotiated rates. When they turned my bill into my insurance company and the claim was denied I got billed for an extra $180($320 total). The denial of the claim freed the doctors office to charge whatever rate they wanted.
I have a gout exclusion because I have had gout a few times in the past, but I am now on Allopurinol and have not had an attack since I started taking that drug.
If the Dr can resubmit with the proper diagnosis the insurance might pay the claim.
If the Dr can resubmit with the proper diagnosis the insurance might pay the claim.
Thanks for your reply, maybe I'm just cynical, but the doctor has little intensive to do that. If he resubmits and the claim and it is accepted he will not get paid any more. The original $140 was supposed to be payment in full. If he does not resubmit or the claim is still rejected, he can get me for an extra $180.
what insurance company do you have your health insurance with? I have never heard of an exclusion for gout or any other medical related illnesses. We have oxford and so far no exclusions.
Thanks for your reply, maybe I'm just cynical, but the doctor has little intensive to do that. If he resubmits and the claim and it is accepted he will not get paid any more. The original $140 was supposed to be payment in full. If he does not resubmit or the claim is still rejected, he can get me for an extra $180.
You have to go in or call and talk to that office. This is a tricky situation because your insurance has excluded coverage of gout since it's a pre-existing condition. They don't want to commit insurance fraud. It will obviously look suspicious to the insurance company if this claim is re-submitted and gout has been removed from the diagnosis. As far as insurance claims goes, they don't see your doctor's exam notes and aren't told of "possible causes". They are given diagnosis codes. The doctor must have submitted gout as the (or one of the) diagnosis.
Your problem is that you went in thinking you had a bone spur, because that's what you were already told. You were expecting to get the negotiated insurance rate. Somehow you were unclear about what the "official" diagnosis was. It's totally reasonable for the doctor to submit the diagnosis of gout to your insurance, based on your history of gout and how your knee looked to him that day.
I suppose your argument is that he wasn't 100% sure that it was gout because he didn't get a blood or joint sample or x-ray. The insurance company will argue that given that the physician believed the cause was gout, it probably was. He did tell you it was not a bone spur based on his physical exam. You don't need to get a new joint or blood sample every time you have a gout flare to prove it's still gout.
Just because you didn't realize you were going to be diagnosed with gout (again) when you went to the urgent care, doesn't mean you aren't responsible for the bill. I'm sure you signed some form acknowledging that the office couldn't guarantee insurance coverage of their services. It's possible that they would consider resubmitting your claim, but they probably won't, because the physician truly believed it was gout. Changing the diagnosis now would constitute insurance fraud. If you want the doctor's office to have them tell you everything I just said, again, then go ahead and go talk to them. Don't expect it to change though. They did nothing wrong. It sucks that you have a pre-existing condition exclusion and that you didn't realize the urgent care had diagnosed you with gout, but that's what happened. You should pay the entire bill. They aren't being unfair.
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