Wellness

[Carmie]

@hckynut   They are diagnostic procedures if you are having symptoms and the doctor was trying to diagnose you.

If you have no symptoms or problems, it is considered preventive. The doctor supplies the codes and the claim is processed according to what is submitted.

When you have insurance through your employer, there is a contract between those two..  It is against the law for insurance companies to pay for something that is excluded from the coverage and also illegal for them to deny a covered services if it meets the terms of your coverage.

I was a rep for a health insurance company for 25 years.  I often had to tell people that things were not covered and my life was threatened over the phone...and one time in person.

if you have group insurance with your employer and have an issue, you should go back to your employer.  There is nothing the insurance company can do for you...even if they wanted to.

I was never happy to tell anyone bad news and that their insurance would not cover something, or worse yet, I could not get a denied claim paid for an excluded procedure.

if you are having a heart attack or have symptoms of having one or have chest pain all tests are covered.  There is nothing preventative about about that.  Also cardiac rehab is covered afterward as a treatment, to hopefully strengthen your heart.

Diagnostic and preventative are two different things.  Also, if something is not covered, it is not covered.

if you do not have car rental insurance on your auto insurance and you are in an accident, your insurance company I not going to pay for you to rent a car until yours is fixed....

 If you don't have coverage for something, it is a done-done deal.

[hckynut]

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@DrakesMomma wrote:

I've worked in medical billing for 21 years.  I applaud you for looking into this before your procedure.  Although you consider yourself as "self-pay" make sure the facility and/or providers bill your insurance company.  They could be contracted with your insurance and may need to take a contractual adjustment.  That could reduce your out-of-pocket. 

Sending good thoughts for a smooth, quick procedure and a good pathology report.  

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@DrakesMomma,

My wife worked close to 35 years as a Medical and Dental Claims Analyst. She also oversaw several of the adjustments to inaccurate Claims filed and/or coded wrong or mistake made by claims Analyst. Thousands of mistakes made in both during her working career.

hckynut

[hckynut]

Hi @Carmie 

Thanks to my wife's decades as an Insurance Claims Analyst, plus overseeing many similar Reps, some of her knowledge actually managed to find a spot in my pea sized brain.

Everything you said CAN be right and most times that might depend on who is negotiating with whom.

But! As one that has had 2 heart attacks, neither of which had the "so-called symptoms"? What was done to me, 1 when I was as wide awake as I am now, falls under preventative.

As far as the ER? They had to Diagnose because no symptoms present concluded I was having a heart attack. Now this was PRIOR to the 12 Lead EKG now carried in most Rescue Units. My 1st attack they were still using a 6 Lead, which told them little.

hckynut

[Carmie]

@hckynut   Everyone's insurance is different.  Original Medicare is set in stone as far as benefits are concerned.

Health insurance for group subscribers is night and day different.  

Codes are sent in by the providers. The insurance companies have nothing to do with  coding.  If a code is incorrect, the provider must correct it.

I have seen claims for a hysterectomy performed on a male named Maria.  Well Maria's husband was really mad about that.  He was double mad that I could not correct it.  I finally called the doctor's office for him and asked them to correct Maria's gender on the claim.

Many years ago, I could change codes that were 100% in error, but the law no longer allows that. All claims are submitted electronically. And to complicate things, if the provider sends in a new claim, it will deny as a duplicate.  They have to correct the original claim.

I too, have seen thousands of coding errors.  It really is a complicated job and not my area of expertise.

[icezeus]

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@Cakers3 wrote:

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@hckynut wrote:

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@icezeus wrote:

I am speechless not only for you, but also for the poor person who had to do the horrible prep only to be told that the procedure would not be covered.

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@icezeus 

Those things should be known well in advance of even scheduling a procedure. The fault is squarely on the shoulders of this "poor person(?)"!  Horrible prep? A little bit of an exaggeration to me.

hckynut

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@hckynutI don't mean to laugh but with as many procedures as you had I would guess you have now acquired a taste for the prep solution.  LOL

My poor son had to consume not 1 but 2 containers of the powder mix over 2 days before his surgery.  He said whoever invented this stuff should be executed.  LOL

It isn't the prep I mind; it's not having anything to eat.  I get cranky.  LOL

My doctor doesn't use go.........lightly.  He uses a liquid you mix with water.

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@Cakers3 @hckynut 

I have highlighted why I said that poor person. I did not mind the procedure, or even the not eating part, I thought that it was bearable. What I could not stand was drinking that god awful tasting solution.

[icezeus]

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@Lipstickdiva wrote:

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@Krimpette wrote:

@Lipstickdiva  I'm surprised the guy who went through all the prep wasn't first notified by his doctor's office that the procedure was not covered.  Glad you didn't first go through the prep!!!!

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@Krimpette, no kidding. I would have been furious because the prep is the worst part.  Or so I've heard.

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@Lipstickdiva 

You heard correctly.

[Cakers3]

@icezeusHi icezeus:  I guess it all depends upon the solution the doctor orders.

Mine was a berry (kind of) flavored liquid I had to mix with water.  It really wasn't bad sipping through a straw. Two 6oz bottles of prep.

That gad-awful powder that comes in that large container-never had the pleasure. LOL

Be well.

[icezeus]

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@Cakers3 wrote:

@icezeusHi icezeus:  I guess it all depends upon the solution the doctor orders.

Mine was a berry (kind of) flavored liquid I had to mix with water.  It really wasn't bad sipping through a straw. Two 6oz bottles of prep.

That gad-awful powder that comes in that large container-never had the pleasure. LOL

Be well.

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@Cakers3 

Wait a minute pump the breakes. LOL You only had to drink two 6oz. size bottles of a berry tasting prep???

I had the god awful powder that you had to mix with water in the huge and I do mean huge container to drink. I was giving some tips to make it more bearable, I chilled it the night before, and added a Crystal light packet, but It was still awful. 

I had my colonoscopy at age 50 and will be 52 this year. I was pleased that my results were good and that I do not need to return until I am 60.

[tobes]

But isn't it diagnostic when the doctor sends tissue in to the lab for confirmation of any cancer?  

[Cakers3]

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@icezeus wrote:

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@Cakers3 wrote:

@icezeusHi icezeus:  I guess it all depends upon the solution the doctor orders.

Mine was a berry (kind of) flavored liquid I had to mix with water.  It really wasn't bad sipping through a straw. Two 6oz bottles of prep.

That gad-awful powder that comes in that large container-never had the pleasure. LOL

Be well.

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@Cakers3 

Wait a minute pump the breaks. LOL You only had to drink two 6oz. size bottles of a berry tasting prep???

I had the god awful powder that you had to mix with water in the huge and I do mean huge container to drink. I was giving some tips to make it more bearable, I chilled it the night before, and added a Crystal light packet, but It was still awful. 

I had my colonoscopy at age 50 and will be 52 this year, and I was pleased that my results were good and that I do not need to return until I am 60.

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@icezeus   Hi icezeus.  Yes.  2-6oz bottles of prep liquid mixed with 16 oz of water per bottle.  Sipped through a straw over a few hours followed by drinking plain water.

One bottle the night before and the second bottle (for me it was 4am because my procedure was first in line that day).

I know the one you mean; that was the one my DS had to take for 2 days.  Two containers although he was having a surgery, not a colonoscopy.

Years ago I had a different prep-something xxx-soda.  Can't remember the name.

It was something to mix and had a lemony flavor.   Oh yummy.  LOL