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Old 12-06-2015, 02:28 PM
 
Location: Washington State
212 posts, read 205,844 times
Reputation: 282

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I made arrangements to get a colonoscopy done at clinic in Washington state, while still under the BCBS FEPBLUE plan.

However, by the time the clinic got back to me to set up an appointment, the next available date for the colonoscopy was in January 2016, by which time I'll be on an exchange based Grouphealth (GH) plan in Washington state.

Upon mentioning this, the appointment setter assured me that the procedure would be covered under Group Health. However, I'm concerned that, in the event of an error, this telephonic assurance won't be of any value.

I see a couple of options other than simply taking the appointment setter's word for it:

(1) I can request that the provider issue a written statement that the procedure is covered by GH well prior to getting the procedure done, and allow my BCBS plan to lapse at the end of December 2015 (it's under the federal version of Cobra).

(2) I can extend the BCBS plan for an additional month (at a cost of about $700).

Does option (1) above recommended, effective, or commonly done? (it seems reasonable given the high cost to me of any misunderstanding).

Option (2) is safer, I guess, but does entail an additional expense I was hoping to avoid.

Thanks for any input.
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Old 12-06-2015, 02:32 PM
 
484 posts, read 449,086 times
Reputation: 901
Quote:
Originally Posted by Voyager39 View Post
I made arrangements to get a colonoscopy done at clinic in Washington state, while still under the BCBS FEPBLUE plan.

However, by the time the clinic got back to me to set up an appointment, the next available date for the colonoscopy was in January 2016, by which time I'll be on an exchange based Grouphealth (GH) plan in Washington state.

Upon mentioning this, the appointment setter assured me that the procedure would be covered under Group Health. However, I'm concerned that, in the event of an error, this telephonic assurance won't be of any value.

I see a couple of options other than simply taking the appointment setter's word for it:

(1) I can request that the provider issue a written statement that the procedure is covered by GH well prior to getting the procedure done, and allow my BCBS plan to lapse at the end of December 2015 (it's under the federal version of Cobra).

(2) I can extend the BCBS plan for an additional month (at a cost of about $700).

Does option (1) above recommended, effective, or commonly done? (it seems reasonable given the high cost to me of any misunderstanding).

Option (2) is safer, I guess, but does entail an additional expense I was hoping to avoid.

Thanks for any input.
Isn't colonoscopy one of the preventive services specifically included under the ACA? I'm not certain, but I know there are other posters who will know for sure.

Another option would be to contact GroupHealth, and ask for the schedule of benefits for your new coverage. It would be listed among the benefits. Or, even, call GroupHealth's customer service directly and ask.
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Old 12-06-2015, 02:34 PM
 
Location: in my mind
5,036 posts, read 7,265,694 times
Reputation: 10123
You may want to do some more investigation and find out which providers/clinics are considered in and out of network for Group Health. Will you have out-of-network coverage for Group Health? Is this clinic part of Group Health? If it is at a GH facility, then it there would be no question that it is in-network.

I am skeptical that a clinic would write you a letter guaranteeing coverage. They tend to say that is between you and the insurance company.

Either way, you will most likely be paying some amount of the cost of this appointment, unless you have a deductible of $0 which is unlikely.
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Old 12-06-2015, 02:36 PM
 
680 posts, read 569,241 times
Reputation: 717
I worked as a medical biller and collector for a gastroenterologist for 16 years. Are you having a routine colonoscopy or are you having it for medical reasons? Most insurance companies cover routine colonoscopies if you are over 50. Some do not cover routine and in that case you just tell the doctor that you sometimes see blood on the toilet paper. The colonoscopy is the same whether routine or medical. Just call the insurance company you will have in January and they will tell you. I do know that some BC/BS plans do not cover routine colonoscopies.
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Old 12-06-2015, 03:01 PM
 
439 posts, read 590,383 times
Reputation: 557
Quote:
Coverage of colorectal cancer screening tests is required by the ACA, but the ACA doesn’t apply to “grandfathered plans”.

Although many private insurance plans cover the costs for colonoscopy as a screening test, patients may be charged for some services. You may have to pay part of the costs of anesthesia, bowel prep kit, pathology costs, and a facility fee (where the procedure is performed). Patients should review their health insurance plan for specific details including if the doctor is within their insurance company’s list of “in-network” providers. If the doctor is not considered in the plan’s network, the patient may face significantly higher cost-sharing.

Colonoscopies that are done to evaluate specific problems, such as intestinal bleeding or anemia, are usually classified as diagnostic – and not screening – procedures. If that’s the case, you may have to pay any required deductible and copay. The same is true if the colonoscopy was done after a positive stool test (such as the FOBT or FIT) or an abnormal barium enema or colonography. Some insurance plans also consider a colonoscopy diagnostic if something is found (like a polyp) during the procedure that needs to be removed or biopsied.

Before you get a screening colonoscopy, ask your insurance company how much you should expect to pay for the exam. Find out if this amount could change based on findings during the procedure. This can help you avoid surprise costs. If you’re hit with large bills afterward, you may be able to appeal the insurance company’s decision.
Source: Colorectal cancer screening ? insurance coverage
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Old 12-06-2015, 05:05 PM
 
Location: R.I.
1,178 posts, read 772,274 times
Reputation: 5280
Quote:
Originally Posted by lindarby View Post
I worked as a medical biller and collector for a gastroenterologist for 16 years. Are you having a routine colonoscopy or are you having it for medical reasons? Most insurance companies cover routine colonoscopies if you are over 50. Some do not cover routine and in that case you just tell the doctor that you sometimes see blood on the toilet paper. The colonoscopy is the same whether routine or medical. Just call the insurance company you will have in January and they will tell you. I do know that some BC/BS plans do not cover routine colonoscopies.
I have Fed BCBS standard and they cover screening colonoscopies, but if the procedure is coded diagnostic and you have not met your $350 annual deductible you will get a $350 bill or whatever the balance that remains of the deductible.
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Old 12-06-2015, 07:35 PM
 
Location: Prescott AZ
6,616 posts, read 10,140,253 times
Reputation: 13042
I would just put off the procedure until February so you have everything in place with the new insurance.
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Old 12-07-2015, 06:51 PM
 
3,613 posts, read 3,407,255 times
Reputation: 5001
Insurance is billed at the time of service so even if you have a pre-auth now, that doesn't mean it will be covered under the plan you have now. It will be covered under whatever plan you have when you have the colonoscopy. I think your provider misspoke or misunderstood what you are asking...or they just don't know the difference.

If the colonoscopy is your preventive one after age 50, it should be covered at 100% either way. What you want to clarify with your provider is how they will CODE that visit.
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Old 12-08-2015, 08:32 PM
 
2,683 posts, read 3,724,878 times
Reputation: 7129
Ask to be placed on the cancellation list and get the colonoscopy done this month.

People cancel all the time.... Especially in a holiday month.

Worked for me last year.
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