topic Re: Who Do I File Complaint for Medical Coding Issue? in Wellness

Who Do I File Complaint for Medical Coding Issue?

BunSnoop — Thu, 23 May 2019 20:21:30 GMT

I had a screening colonoscopy performed. My doctor and hospital billed using a preventive medical billing code. Insurance paid 100%

The pathologist billed with a code of a illness (benign polyp). Insurance applied charge to deductible.

Called insurance - told me I need a corrected bill from pathologist and they will then be able to pay bill as preventive - 100%.

Called pathologist and also sent a letter of appeal. They state that even though the colonoscopy was preventive, as soon as they review the specimen and find a polyp, a hemorrhoids, etc. the diagnosis is an illness not preventive.

I explained that due to Health Care Reform a patient is not to have any cost-sharing expenses for network preventive services that fall within the guidelines of the US Department of Health and Human Services guidelines. I continued to state that CMS.GOV states that if a colonoscopy is scheduled and performed as a screening procedure it is not permissible for a plan or issuer to impost cost-sharing for any related services. Whether a polyp or cancer is ultimately found does not change the screening intent of that procedure.

The supervisor at the pathology department said he does not agree with me. I said I want to continue to pursue that and I wanted his explanation provided to me in writing. He said he can not do that. I told him that his office told me to appeal and I had to send a "dispute letter". I did that and also attached copies of my drs. bills with preventive dx, etc. I expect him to give me the courtesy of answering my letter in writing - not just verbally. He said they do not write letters. Finally, he gave me the phone number of his supervisor and I left a message.

Do you agree that they should respond to my dispute letter in writing not just verbally?

If this still does not get resolved, do you know who you file complaints to regarding medical billing issues? Is it the states attorney office, I don't think the Better Business Bureau.

Can anyone suggest who I would next file the complaint with?

Thank you. I'm sooo frustrated with this. Today was a day off from work, they called this morning, and I've been upset the rest of the day. I'd appreciate any help.

Re: Who Do I File Complaint for Medical Coding Issue?

HerRoyaLioness — Thu, 23 May 2019 20:27:40 GMT

The pathologist has to bill what they found, what he is examining. In this case it was a polyp. It was coded correctly. Your insurance should know that.

Re: Who Do I File Complaint for Medical Coding Issue?

Mz iMac — Thu, 23 May 2019 20:30:14 GMT

File a Complaint - healthfinder.gov

https://healthfinder.gov/FindServices/SearchContext.aspx?topic=14309

Re: Who Do I File Complaint for Medical Coding Issue?

chrystaltree — Thu, 23 May 2019 21:16:34 GMT

I'm not quite sure what your complaint is, the following is correct :

"Called pathologist and also sent a letter of appeal. They state that even though the colonoscopy was preventive, as soon as they review the specimen and find a polyp, a hemorrhoids, etc. the diagnosis is an illness not preventive."

It doesn't matter that the colonoscopy was ordered as a preventative test; once the polyp was identified, it was no longer preventative. You are talking money but medical coders and billers and insurers go where the clinical leads them. In your case the clinical leads them to a diagnosis of colon polyps and that is how the claim would be adjudicated. You have appeal rights so file an appeal with your insurer. They will review the appeal and you will get a written determination. Of course the pathologist isn't going to address any of this in writing, you dispute is with the insurer. He was right, you have to file an appeal with your insurer. That's not to say that you have anything to appeal.

Re: Who Do I File Complaint for Medical Coding Issue?

FranandZoe — Thu, 23 May 2019 20:39:27 GMT

Your State Insurance Commission.

Re: Who Do I File Complaint for Medical Coding Issue?

Gracies Mom — Thu, 23 May 2019 21:09:01 GMT

I agree with you HerRoyalLioness---the polyp was coded correctly.

What if a person had a screening mammogram and a mass was found---the coded diagnosis would be what was found. The fact that the reason for the mammogram (or colonoscopy) was a screening--could be coded as a secondary diagnosis.

It's true that insurance companies should know that. They look for excuses not to pay.

Hope this issue works out.

Re: Who Do I File Complaint for Medical Coding Issue?

BunSnoop — Thu, 23 May 2019 21:14:31 GMT

I forgot to mention, I've been employed by a health insurance company for over 40 years. I'm a former medical claims examiner and now a plan document writer.

I'm familiar with federal regulations and according to Health Care Reform whether a polyp or cancer is ultimately found does not change the screening intent of that procedure.

Insurance will reconsider this bill as preventive when they get a corrected bill from pathology. The Primary ICD.10 code needs to be preventive and the secondary code(s) related to the results or findings.

I need to know who to contact to file a complaint regarding the pathology billing company not the insurance company.

Re: Who Do I File Complaint for Medical Coding Issue?

chrystaltree — Thu, 23 May 2019 21:26:12 GMT

@BunSnoop wrote:
I forgot to mention, I've been employed by a health insurance company for over 40 years. I'm a former medical claims examiner and now a plan document writer.

I'm familiar with federal regulations and according to Health Care Reform whether a polyp or cancer is ultimately found does not change the screening intent of that procedure.

Insurance will reconsider this bill as preventive when they get a corrected bill from pathology. The Primary ICD.10 code needs to be preventive and the secondary code(s) related to the results or findings.

I need to know who to contact to file a complaint regarding the pathology billing company not the insurance company.

If you suspect that the pathologist billed with an incorrect diagnosis, you file a complaint with your insurance company. The reason for that is that your belief is that the pathologist submitted a bill....to your insurer....that had incorrect information on it. I know you want to hear that the pathologist did something wrong but he didn't and did the right thing by reviewing it for you and responding to your inquiry promptly and professionally. He doesn't have to change the diagnosis just because that's what you want. Your only recourse is to call the insurance company, state your case, and ask how you formally dispute the charge he billed. The lab billing company billed the insurer, they didn't bill you directly. The insurance company will review the diagnosis issue and act accordingly.

Re: Who Do I File Complaint for Medical Coding Issue?

Caffeina — Thu, 23 May 2019 21:59:28 GMT

That's normal for insurance companies to do that, and it's legal. Mine did the same until this year. It's probably spelled out in your policy. Even Medicare does it.

I believe what you cited from the CMS site applies to ACA plans, and not private insurance.

https://www.medicare.gov/coverage/screening-colonoscopies

Re: Who Do I File Complaint for Medical Coding Issue?

BunSnoop — Thu, 23 May 2019 22:13:14 GMT

The information quoted is from the Affordable Care Act. It applies to my insurance which is a self-funded non-grandfathered health plan.

Re: Who Do I File Complaint for Medical Coding Issue?

BunSnoop — Thu, 23 May 2019 22:34:53 GMT

They do not handle anything promptly and professionally. It took, and I am not exaggerating, 18 phone calls to their office in 1 year to get the claim filed to my insurance.

They filed the claim originally to a insurance company I never had. I sent a letter with the correct insurance information, they never updated my file with that information. Then once they had acknowledged they filed the claim to my insurance and my insurance had no record of it being received, they would never resubmit it. They always said "too soon - we have to wait 90 days"! Also, they never could provide an actual date as to when they sent the claim to insurance.

I told them that I have a 1 year filing submission clause, the claim must get to the insurance before that time or it will be denied for timely filing. I spoke to supervisors and they told me not to worry, if they don't get the claim to my insurance in time, they'll write it off.

Sure does not sound too prompt and professional that they may not be able to get a claim filed IN ONE YEAR, so they rather just write it off???? How efficient / professional is that? I consider their practices unacceptable.

I could go on and on about the experiences I had with them and, therefore, as they say "considering the source" I know I'm dealing with a billing service that is very inadequate.

Thank you to those of you that provided some assistance with who I can contact to file a complaint - I appreicate your help.

Oh yes, and when I called today. The first thing that the rep. said to me is 'I see you have a balance on your account and WE HAVE NO RECORD OF YOU HAVING INSURANCE". Really, I only called 18 times previously with that information!!! No - this is NOT a professional company.

Re: Who Do I File Complaint for Medical Coding Issue?

Jinlei — Fri, 24 May 2019 00:07:02 GMT

I do coding for a living and how do you think a pathologist can code something other than a polyp? That is what was found, that is what has to be coded or it is fraud, plain and simple. Call The Office of the Inspector General if you do not agree. I used to work at a multi-specialty clinic and patients always wanted their claims recoded so their insurance would pay. You can only code what is found, in this case a polyp.

Re: Who Do I File Complaint for Medical Coding Issue?

BunSnoop — Fri, 24 May 2019 00:17:49 GMT

The PRIMARY diagnosis should be the same as the ordering physician's and the facility bill - screening. The patient had no symptoms or complaints when the procedure was ordered/performed.

The pathologist should list as the SECONDARY diagnosis the results of the screening - polyps.

Re: Who Do I File Complaint for Medical Coding Issue?

Jinlei — Fri, 24 May 2019 01:10:13 GMT

Hutchill-You are absolutely correct.

Re: Who Do I File Complaint for Medical Coding Issue?

Kachina624 — Fri, 24 May 2019 02:40:20 GMT

@HerRoyaLioness wrote:
The pathologist has to bill what they found, what he is examining. In this case it was a polyp. It was coded correctly. Your insurance should know that.

@HerRoyaLioness @BunSnoop. If the pathologist just removed a polyp, he doesnt know whether or not its diseased. Removing it is part of the diagnostic process.

I'd call your state's insurance regulatory agency and ask who would oversee such a situation.

Re: Who Do I File Complaint for Medical Coding Issue?

chrystaltree — Fri, 24 May 2019 12:57:18 GMT

@BunSnoop wrote:
The PRIMARY diagnosis should be the same as the ordering physician's and the facility bill - screening. The patient had no symptoms or complaints when the procedure was ordered/performed.

The pathologist should list as the SECONDARY diagnosis the results of the screening - polyps.

Wrong!!!!!

Re: Who Do I File Complaint for Medical Coding Issue?

CelticCrafter — Fri, 24 May 2019 19:28:17 GMT

@Gracies Mom wrote:
I agree with you HerRoyalLioness---the polyp was coded correctly.

What if a person had a screening mammogram and a mass was found---the coded diagnosis would be what was found. The fact that the reason for the mammogram (or colonoscopy) was a screening--could be coded as a secondary diagnosis.
It's true that insurance companies should know that. They look for excuses not to pay.

Hope this issue works out.

I could be wrong but in the case of a preventative mammogram a biopsy isn't done on the spot.

Re: Who Do I File Complaint for Medical Coding Issue?

Gracies Mom — Fri, 24 May 2019 20:33:35 GMT

Of course a breast biopsy is not done on the spot if anything suspicious is found on a mammogram--but the fact an abnormality--a mass--was found--that can be coded as such.It's the same issue as the polyp found on a colonoscopy--a biopsy is not done on the spot--but just the fact it was there is codable.

Re: Who Do I File Complaint for Medical Coding Issue?

GiantsLover — Fri, 24 May 2019 20:40:19 GMT

Thanks for posting this thread.

Re: Who Do I File Complaint for Medical Coding Issue?

Still Raining — Fri, 24 May 2019 20:55:05 GMT

The pathologist can not use a ICD-10 code for a colonoscopy. His primary diagnosis would be something like K63.5.

The bill itself would be the PC of the CPT from the physician fee schedule on a 1500. Perhaps 88304?

If the facts are as stated, the bill would require modifier 33 to remove the patient responsibility. That should be true for the TC too.

It has been a while and I seem to recall some trap about the CPT?