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Insurance Question about Coverage

Lipstickdiva — Wed, 21 Oct 2015 18:46:07 GMT

I know I need to contact the plan administrator about this but I am just wondering if anyone has ever heard of this situation because I haven't before.

I have health insurance with DH through his employer. It's referred to as employee + 1 coverage and it's through BCBS. We have had this coverage for 7 years. Every year, I have routine bloodwork done which includes having my cholestrol checked.

This year, I rec'd my EOB and everything regarding my bloodwork was paid except my cholestrol test. They denied payment on that. I called BCBS and was told it was because my physician's office coded it incorrectly.

Long story short, I received a letter indicating that under our plan, cholestrol tests are only covered for the employee, not family members. This has to be a new change as it's always been covered in the past. But this doesn't make any sense to me. If we are paying for coverage, I don't understand how they will pay for coverage of some things for only 1 person on the plan and not everyone?

I'm going to look into this further but wondered if anyone ever ran into this and if it's common.

Re: Insurance Question about Coverage

terrier3 — Wed, 21 Oct 2015 19:00:25 GMT

@Lipstickdiva wrote:
I know I need to contact the plan administrator about this but I am just wondering if anyone has ever heard of this situation because I haven't before.

I have health insurance with DH through his employer.  It's referred to as employee + 1 coverage and it's through BCBS. We have had this coverage for 7 years. Every year, I have routine bloodwork done which includes having my cholestrol checked.

This year, I rec'd my EOB and everything regarding my bloodwork was paid except my cholestrol test. They denied payment on that. I called BCBS and was told it was because my physician's office coded it incorrectly.

Long story short, I received a letter indicating that under our plan, cholestrol tests are only covered for the employee, not family members. This has to be a new change as it's always been covered in the past.  But this doesn't make any sense to me. If we are paying for coverage, I don't understand how they will pay for coverage of some things for only 1 person on the plan and not everyone?

I'm going to look into this further but wondered if anyone ever ran into this and if it's common.

I don't work in CS - I sell policies - but this is weird.

Was this part of your annual "well" visit? If so, it should be included at NC.

Unless you have a chronic problem and are on meds for that issue. Then it wouldn't be a free well visit, but ongoing treatment.

May I suggest that you talk to the MDs billing department and see if they can re-code it and send back to BCBS?

Re: Insurance Question about Coverage

straykatz — Wed, 21 Oct 2015 19:20:49 GMT

I does sound like a coding issue. Have you contacted your doctor office? I had a similar thing happen to me a couple years ago and my doctor resubmitted without question.

Re: Insurance Question about Coverage

Big Sister — Wed, 21 Oct 2015 19:31:12 GMT

You're right, I think, this doesn't make sense. Your doctor's biller should resubmit the claim with the correct coding.

Re: Insurance Question about Coverage

Winkk — Wed, 21 Oct 2015 19:33:02 GMT

It may be a coding mistake by your doctor's office. I read that a lot of new codes were added the beginning of October, the office may have put in the wrong one.

Re: Insurance Question about Coverage

GCR18 — Wed, 21 Oct 2015 19:42:46 GMT

I'd call BCBS back and talk with someone else. I just spent six weeks straightening out 2 bills they declined. Their final outcome was one bill would be paid, but not the other because it was experimental. Nothing about my radiation treatments were experimental. The next day I went into my BCBS page and they paid the bill their rep told me wouldn't be paid.

Re: Insurance Question about Coverage

2blonde — Wed, 21 Oct 2015 19:43:04 GMT

I hate to say it, but what the insurance company is telling you may be true. I have a friend who works with me, and her husband worked here also (he's recently retired). When he was here he was the primary insured and she was the dependent on their employee provided insurance. (By using only his coverage, she received a $2,000/yr rebate on her paycheck for not having her own policy as an employee. There were certain tests and preventative procedures that were not covered for her, but were covered for him under the plan.

Re: Insurance Question about Coverage

straykatz — Wed, 21 Oct 2015 19:48:20 GMT

@GCR18 wrote:
I'd call BCBS back and talk with someone else. I just spent six weeks straightening out 2 bills they declined. Their final outcome was one bill would be paid, but not the other because it was experimental. Nothing about my radiation treatments were experimental. The next day I went into my BCBS page and they paid the bill their rep told me wouldn't be paid.

Got to love those reps....I recently argued with my dental insurance because they said I had 3 cleanings in 1 year and I am only allowed 2. So what happened was my checkup got scheduled 2 days too early which meant I went 3 times in a 12 month period. Seriously!!!....I was wild!!.....and only after I flipped out did she offer to cover it as a one time courtesy because I went 2 days too soon. How ridiculous is that!

Re: Insurance Question about Coverage

Lipstickdiva — Wed, 21 Oct 2015 21:01:00 GMT

This was part of my well visit and it's not no charge because DH's insurance doesn't have to follow the new HC laws yet so they aren't. I still had to pay for my mammo this year too.

First I was told when I called that it was a coding issue. So I called my doctor's office and they said it was coded correctly and they absolutely were not going to recode it.

I called BCBS again and spoke to someone different. To me there was no way it could be a coding issue because all my other bloodwork was paid, it was just the cholestrol that was denied. It was paid last year and she went back and looked and it was coded the same way last year as this year. The rep put me on hold, came back and said that a supervisor said it needed to be sent back to another dept. and given an override code and would be paid. Then as the girl was e-mailing the other dept., she read in my contract that a cholestrol test wasn't covered for me, only my DH. She said she was submitting it anyhow to see what happened. About a week later I received the letter indicating this test wasn't covered for me and if I had further questions, I needed to contact the employer.

I left a message at DH's employer for them to call me back about this. I know I saved my insurance book but do you think I can find it? Of course not.

Re: Insurance Question about Coverage

kitty60 — Wed, 21 Oct 2015 22:08:31 GMT

I have BC in SC and every year I have to go a round with them to have my phyical paid as it should be. I can pull up my coverage on their site and clearly see what it covers. I then refer them to the site. It can take me up to three reprocessings to get it paid! Don't give up.

Re: Insurance Question about Coverage

brii — Thu, 22 Oct 2015 12:53:55 GMT

OMgosh, that really stinks.

I would just assume everybody under that policy had the same coverage.

Re: Insurance Question about Coverage

CouponQueen — Thu, 22 Oct 2015 15:27:25 GMT

How come they are exempt from the new health care law?

Re: Insurance Question about Coverage

Lipstickdiva — Thu, 22 Oct 2015 15:30:42 GMT

@CouponQueen wrote:
How come they are exempt from the new health care law?

When the new HC laws become mandatory, they will have to comply. Right now it is optional for old plans to follow the new HC laws. They are grandfathered in so to speak and it's their choice whether they want to follow the new reform or not. They are choosing not to but won't have that choice much longer.

Re: Insurance Question about Coverage

Lipstickdiva — Fri, 23 Oct 2015 19:12:16 GMT

Just spoke with the rep. at DH's employer and he confirmed that routine cholestrol tests are paid for employee only. He said if it's put through as medically necessary, it would be paid for me as well.

My doctor's office flat refuses to recode this as medically necessary because it was my yearly, routine physical. This was a new doctor for me and they required I have this done to become a patient. But it's something that should be done yearly anyhow.

So I guess I will be paying the $100.00+ for this test.

Re: Insurance Question about Coverage

terrier3 — Fri, 23 Oct 2015 19:14:51 GMT

@Lipstickdiva wrote:
@CouponQueen wrote:
How come they are exempt from the new health care law?
When the new HC laws become mandatory, they will have to comply. Right now it is optional for old plans to follow the new HC laws. They are grandfathered in so to speak and it's their choice whether they want to follow the new reform or not. They are choosing not to but won't have that choice much longer.

I remember that they originally WEREN'T supposed to be grandfathered in for this long...but people objected loudly and they relented.

It doesn't sound like a great idea now, does it?

States regulate insurance. NY doesn't have those types of policies and hasn't for decades.

Re: Insurance Question about Coverage

RainyDayGal — Fri, 23 Oct 2015 19:16:11 GMT

Wow. Next time just go to Walgreens or something and get the finger poke. I do think the lab should have told you the test might not be covered, but maybe they didn't know. I know when I get my Vit. D test, the first time it was covered, then all of a sudden I was informed it might not be. Fortunately, they are, but now everytime I have it done I have to sign something saying I agree to pay for it if isn't.

Re: Insurance Question about Coverage

chrystaltree — Fri, 23 Oct 2015 19:34:05 GMT

Look it up in the insurance booklet you have, the one that explains your coverage. Use the current book. That they would cover that lab test for the employee but not for dependants just doesn't seem right. It doesn't make any sense. Before you look it up yourself, call BCBS back and ask another cs rep. It's possible that the employer changed coverage and cholesterol screeing isn't covered every year. As for your doc's office coding the cholesterol lab wrong. If that were the case, how would you or BCBS know that the denied charge was for the cholesterol test? Medical claims aren't billed with words, they are billed with procedure codes. So if the doc's office used the wrong code for the cholesterol test, you wouldn't know that. For example, if they incorrectly billed 87275 instead of the correct code for cholesteral. You would have received a denial for 87275, which is influenza B virus screening. The computer system that processed your claim would know that you had your cholesteral checked.

Re: Insurance Question about Coverage

HappyDaze — Fri, 23 Oct 2015 19:34:34 GMT

@Lipstickdiva wrote:
Just spoke with the rep. at DH's employer and he confirmed that routine cholestrol tests are paid for employee only. He said if it's put through as medically necessary, it would be paid for me as well.

My doctor's office flat refuses to recode this as medically necessary because it was my yearly, routine physical. This was a new doctor for me and they required I have this done to become a patient. But it's something that should be done yearly anyhow.

So I guess I will be paying the $100.00+ for this test.

That is crazy! I've never neard of an employer plan only paying 100% of the employee's preventative tests and not the covered spouse or children! I just went to our healthcare changes meeting and they said the cholesterol, mammo, pap, colonoscopy, etc are all covered 100% for all covered. It makes no sense for them to cover only the employee since it is preventative and what does it hurt them to pay the $100+ bill for a preventative thing rather than have someone go without and then end up with a $100K + bill for a heart attack or something that can be a result of high cholesterol. Prevention is the key and I would have thought insurances were getting better about paying for preventative exams/tests.

By the way, many hospitals/drs. offices will give you a 10% (or more) discount if you pay the bill in full within so many days of the invoice. I am going to be saving almost $400 on my husband's bill for doing so. Everyone should check into these types of things to save money.

Re: Insurance Question about Coverage

Ibby114 — Fri, 23 Oct 2015 19:39:18 GMT

@HappyDaze wrote:
@Lipstickdiva wrote:
Just spoke with the rep. at DH's employer and he confirmed that routine cholestrol tests are paid for employee only. He said if it's put through as medically necessary, it would be paid for me as well.

My doctor's office flat refuses to recode this as medically necessary because it was my yearly, routine physical. This was a new doctor for me and they required I have this done to become a patient. But it's something that should be done yearly anyhow.

So I guess I will be paying the $100.00+ for this test.
That is crazy! I've never neard of an employer plan only paying 100% of the employee's preventative tests and not the covered spouse or children! I just went to our healthcare changes meeting and they said the cholesterol, mammo, pap, colonoscopy, etc are all covered 100% for all covered. It makes no sense for them to cover only the employee since it is preventative and what does it hurt them to pay the $100+ bill for a preventative thing rather than have someone go without and then end up with a $100K + bill for a heart attack or something that can be a result of high cholesterol. Prevention is the key and I would have thought insurances were getting better about paying for preventative exams/tests.

By the way, many hospitals/drs. offices will give you a 10% (or more) discount if you pay the bill in full within so many days of the invoice. I am going to be saving almost $400 on my husband's bill for doing so. Everyone should check into these types of things to save money.

It's a way for a company to cut corners on health insurance plans. I had this problem when my kids were covered under my ex's plan- his planinitially seemed great becasue you didn't need to get the dreaded referrals. But then so many things weren't covered for my kids. And of course it was found out after the fact! We're still fighting a bill from June 2013.

Re: Insurance Question about Coverage

Lipstickdiva — Fri, 23 Oct 2015 19:49:34 GMT

@chrystaltree wrote:
Look it up in the insurance booklet you have, the one that explains your coverage. Use the current book. That they would cover that lab test for the employee but not for dependants just doesn't seem right. It doesn't make any sense. Before you look it up yourself, call BCBS back and ask another cs rep. It's possible that the employer changed coverage and cholesterol screeing isn't covered every year. As for your doc's office coding the cholesterol lab wrong. If that were the case, how would you or BCBS know that the denied charge was for the cholesterol test? Medical claims aren't billed with words, they are billed with procedure codes. So if the doc's office used the wrong code for the cholesterol test, you wouldn't know that. For example, if they incorrectly billed 87275 instead of the correct code for cholesteral. You would have received a denial for 87275, which is influenza B virus screening. The computer system that processed your claim would know that you had your cholesteral checked.

I don't have my book as I explained above. My DH's employer read me the section out of the coverage book and it says it's not covered for anyone but the employee. Same with the PSA test, which obviously I don't need.

I can go on-line to BCBS website and review all of my claims and the claim detail. For this particular visit, my claim detail lists everything they did that day in the lab and how much each procedure was and what my insurance paid. Next to the one that says "Lab Cholesterol" it had a code and showed $0.00 being paid by my insurance. The code was that according to our plan certificate, this isn't covered for a non-employee.

Of course if you call a rep at your insurance company, they know everything that was submitted and why it wasn't paid. I don't understand why you think the insurance company would be looking at a procedure code and not able to tell what that corresponded to. They'd have to know that.

I've now talked to a BCBS rep 3 times. Without it being recoded by my doctor's office as medically necessary, it will not be paid.