Insurance Won't Pay for Preventive Colonoscopy! - Page 8

Carmie · ‎10-25-2010

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

If there is nothing there that looks suspicious, there is no tissue taken to send to the lab.

If you have polyps, they will be removed and sent to the lab and hopefully the doctor will code the claim as diagnostic.

hckynut · ‎03-10-2010

@Carmie

I certainly get it. My wife worked at different insurers over her decades, some were 3rd party insurers. Policies are as different as night and day, and how much one wants to pay, has everything to do with what is included in their policies. She started as a phone Rep, and even those that did the coding weren't sure of what they were doing.

In spite of my wife's knowledge, I spent many hours on the phone with the insurers reps. If I couldn't get through to them with what I knew, I would call in my wife to settle our disagreements.

I know for sure that any type of insurance agent be it home/car or medical, if they could not point out to me in my policies our discrepancies, the battle is on. Lost a few with 2 of the above mentioned, but was successful more than not. Many don't want to spend hours over maybe even a few $$$, that is not me.

hckynut

hckynut(john)

Snoopp · ‎02-02-2015

@Carmie wrote:
@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.

Coding seems to an area that changes frequently. I'm glad that at least some codes can be found online.

depglass · ‎03-10-2010

And one wonders why insurance companies have such bad reputations.

nomless · ‎03-10-2010

I'm sorry that the insurance company is getting dissed so strongly. In a previous post, OP wrote that that the fault is with not with the inurance company but with the plan the employer chose. The insurance company has other plans that do cover the procedure. Apparently the employer could not or did not want to go with a plan that offered more benefits at (probably) a higher cost to the employer.

Lipstickdiva · ‎03-10-2010

@lovesrecess wrote:
I would find out exactly how much you will be paying before you drink the first bit of that yucky prep stuff.

@lovesrecess, they gave me a price.

And I am lucky if you want to call it that. This doctor does the laxative and Gatorade/Propel/Crystal Light prep.

Lipstickdiva · ‎03-10-2010

@PamfromCT wrote:
I might be in the minority here, but my preps for colonoscopies has not the the ultimate horror show. You drink and go to the bathroom. Not pleasant, but not the worst thing.

I am so sorry you are having to endure problems in payment from your insurance company. I look forward to the day that insurance companies, which exist just to make a profit, are not in charge of health care. Your experience is shameful. Best of luck to you. The whole process will be much smoother than you think. Nowadays the anesthesia takes hold so fast, when you open your eyes it will all be over. Really!
Pam

@PamfromCT, I am not worried about the actual test itself, it was the prep I was concerned about. I have a very sensitive stomach and it gets upset very easily drinking funky stuff. I had a hard time drinking barium for a CT Scan. I was gagging trying to get it down. Luckily, my doctor doesn't do the Go-Lightly prep so I think I'll be okay. I don't love Gatorade or Propel but it's better than that other stuff. LOL

I had to have an endoscopy a few years ago and they did the same twilight sleep. I remember being awake then I wasn't, then I was awake. I remember nothing else. Works for me.

Trinity11 · ‎11-16-2014

@depglass wrote:
And one wonders why insurance companies have such bad reputations.

From what I have read it has more to do with what particular Plan the employer chooses to insure their employees. My husband had a choice of 3 and we chose the highest tier because I have a lot of medical issues. If we had chosen the lowest tier, my heart attacks back in 2016 and 2017 would have been catastrophic in co-pays.

Lipstickdiva · ‎03-10-2010

@hckynut wrote:

@Lipstickdiva ,

Not sure I follow you. You first say Colonoscopy and later say Endoscopy! Um, having had 15 of 1 and at least 25-30 of the other, the scope goes in opposite ends of the body.

This is a "catch 22" or "chicken or the egg" nonsense. Both of these are "diagnostic procedures" and I would dare any insurance rep to try to tell me differently. These are done Firstly to Diagnose and Secondly to Prevent, in that order.

Even having a heart attack and going to an ER, FIRST comes the Diagnosis, SECOND comes the Prevention. Sounds like an Insurance rep that knows squat, my wife worked for years with some exactly like them.

Were this me? They would have a big fight on their hands in trying to explain "Prevention verses Diagnostic" and which came first "the chicken or the egg"?

"Dreaded", really?

hckynut

@hckynut, I am having a colonoscopy. When I called my insurance, the rep told me that preventive endoscopic procedures aren't covered. I went and did some research because when someone says endoscopic procedure, I thought endoscopy and was thinking she's talking about the wrong end. LOL

However, there are 13 procedures that are considered an "endoscopic" procedure and a colonoscopy is one of them as is a sigmoidoscopy and then 11 others that I don't remember. Another poster questioned this as well also thinking an endoscopic procedure meant an endoscopy.

My insurance company, and I am sure many if not most others, consider this a preventive or screening test unless you have a symptom or problem they are checking for in which case it then becomes diagnostic. This is my first one ever because I am 51 so it's considered preventive/screening. They handle this the same way they handle mammograms. They are considered screening/preventive unless you have an issue they are looking for and then they are considered diagnostic. Maybe for you all of yours are considered diagnostic.

Some people have real issues with that prep. They cannot handle it. I have several nurses in my family and they have said that some patients become very ill from some of the preps and end up vomiting, getting chills, etc.

Lipstickdiva · ‎03-10-2010

@NicksmomESQ wrote:
@Cakers3 Wow!! I get what you’re saying.I would still file a grievance & press the point.I would also check into the state & other Federal laws that you mention.
I say this because a few years ago I helped a friend get something covered by her medical insurance that they insisted wasn’t covered.It took me several months & countless calls.
Personally,I think the whole medical system is corrupt on so many levels, & has been for decades. We have a broken system that doesn’t look like it’s about to be fixed anytime soon.

@NicksmomESQ, unfortunately there is nothing I can do. This iinsurance plan is grandfathered in so they do not have to cover wellness exams, preventive testing, etc. Until they are mandated to do so, that's just the way it is.

I got out the insurance book again last night and went through it with a fine tooth comb. Further on, they specifically state that preventive endoscopic procedures such as a colonoscopy and sigmoidoscopy are not covered.

I even researched how an insurance plan can lose their grandfathered status but none of that applies. So at this point, it is what it is.

I've had claims denied and gotten them paid on appeal because they should have been paid. That's different then having something paid for that is specifically excluded under the plan.