Insurance Question about Coverage - Page 3

millieshops · ‎03-09-2010

Years ago I remember hearing some TV commentator say that one of the best ways to save money was to stay healthy. Of course, he was right, but who really knows how to do that 100%. That's what insurance should be for!

Lipstickdiva · ‎03-10-2010

I would think that the insurance company would rather pay $111.00 for a cholestrol test than pay for all the problems you could end up with as a result of high cholestrol you don't know you have because you don't get the test done.

Apparently other employees' family members must not go for routine bloodwork because when I called the insurance rep., he said I was the first one that had ever questioned this or brought it to his attention and he was going to bring it up at the next meeting and see why they did this.

RainyDayGal · ‎03-09-2010

So why won't the doctor's office recode and resubmit? I don't understand that. Is it some big time-consuming hassle? Do they make less money?

chrystaltree · ‎05-10-2010

@Lipstickdiva wrote:
@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.

I have worked both sides; for BCBS for 10 years and for hospitals and doctors offices for 20 years. There is nothing I don't know about healthcare billing and coding. The reps you speak to at insurance companies cannot possibly know every procedure code. There are about 20,000!   It's 2015, no one "knows" this stuff anymore. When you called about the denied charge, the rep looked it up on his or her computer screen because I assure you, he doesn't know all 20,000 Hcpc codes by heart. Insurance reps don't even have CPT or Hcpc books, they depend on their screens.  Of course, you doc's office won't recode the claim. They can't. They coded it correctly and the charge denied correctly because you don't coverage for it. If they recoded it just to get paid, they would be guilty of fraud. I also worked as investigator for BCBS once and that's exactly the type of thing we looked for. We would match what was on the bills to the medical records, to ensure that docs offices were fraudulently billing. I do think this story is lesson for others. Save those insurance booklets they give you! They give them to us for a reason.

Lipstickdiva · ‎03-10-2010

2 reps at BCBS are the ones who TOLD me to call my doctor's office and have them recode it so it would be paid. I didn't come up with that on my own. I never would have thought about that.

The BCBS reps don't have to know the billing codes by heart. There is detail in the computer about everything that was done. It's on their end and my end because she read it to me off her screen and I followed along on mine.

60sgirl · ‎11-24-2014

@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.

that is incorrect information. A procedure code (CPT) 87275 is just the code used for the lab test itself. A doctor cannot miscode that. It is standard for that test. A diagnostic code (ICD-9) is used by the doctor's office for billing and can be changed by the doctor i.e. used either for routine testing or diagnostic testing. If a person has a medical history of high cholesterol and takes maintenance medication, checking a lipid profile is done diagnostically and is covered unless done extensively. If done once a year during a wellness physical, it is routine and many routine tests are not covered unless they meet certain guidelines set up by the provider i.e. annually only in most cases.

In OP's case it was neither but as she explained a change in her coverage guildelines that she did not know about before the test was done. Reading through an insurance booklet and understanding every line item can be tedious and hard to follow and often people aren't aware of exclusions until something gets denied and then they have to research it. It happens all the time.

I'm done with P.C. Just say what you mean and mean what you say. It's easier.

CelticCrafter · ‎03-09-2010

@RedConvertibleGirl wrote:
So why won't the doctor's office recode and resubmit? I don't understand that. Is it some big time-consuming hassle? Do they make less money?

It would be fraud...