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Trusted Contributor
Posts: 1,408
Registered: ‎05-22-2010

Who Do I File Complaint for Medical Coding Issue?

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.

Respected Contributor
Posts: 2,599
Registered: ‎03-13-2010

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

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. 

Honored Contributor
Posts: 16,447
Registered: ‎07-26-2014

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

File a Complaint - healthfinder.gov

 

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

"Never argue with a fool. Onlookers may not be able to tell the difference."


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Honored Contributor
Posts: 27,404
Registered: ‎05-10-2010

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

[ Edited ]

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.  

Respected Contributor
Posts: 3,247
Registered: ‎03-09-2010

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

Your State Insurance Commission.

Valued Contributor
Posts: 830
Registered: ‎04-25-2011

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

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.

Trusted Contributor
Posts: 1,408
Registered: ‎05-22-2010

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

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.

Honored Contributor
Posts: 27,404
Registered: ‎05-10-2010

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


@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. 


 

Trusted Contributor
Posts: 1,358
Registered: ‎03-09-2010

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

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

Trusted Contributor
Posts: 1,408
Registered: ‎05-22-2010

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

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