I am pregnant, and was referred to a maternal fetal medicine specialist for a first-trimester screening based on my risk factors. At the appointment, I received a single ultrasound.
I was billed for a “first trimester screening” and “nuchal translucency scan”, this making it appear I received two ultrasounds in the same day for no good reason. Based on that, my “second” ultrasound was denied and I am being charged $800.
I’m working with the medical office on this, but if it can’t be resolved I plan to request an appeal. Do you have any suggestions on how to phrase this or what to do?
I’ve been on the phone with them for hours, but they are being coy with me. It took me three hours and five phone calls just to get to the bottom of what actually happened.
The issue isn’t with your insurance company, it’s with your physician. Talk to their back office and explain that apparently they coded something wrong and that your insurance company, nor you plan on paying for two ultrasounds when only one was done.
Talk to your doctor’s office. More than likely, their insurance billing clerk coded the ultrasound incorrectly - resulting in the insurance carrier seeing it as two separate operations.
I get steroid shots in both my shoulders every six months. I specifically have them done in two separate appointments - although that’s an inconvenience - because if I don’t, the insurance carrier invariably denies one of them as a duplicate serivce.
Is your medical provider associated with a larger hospital or medical center? If so there is likely an ombudsman or a “patient satisfaction office” that you can threaten to access to *encourage *the office staff re-code the procedure so it’s corrected. If they still don’t, then you would of course follow through, and at that point they should be forced to correct it so they don’t make the hospital/medical center look bad.
Make a fuss about it, but be polite while making a fuss. They likely get a lot of money off of people who aren’t willing to be a bother or be “rude” to their doctors. Asking them to correct their mistake (if done calmly and politely) no matter how many times you have to ask them, isn’t rude or a bother even though they’l do their best to make you feel like it is.
This. Have you received an actual bill for $800, or just a statement from your insurance that your “patient responsibility” is that amount? Your doctor is the one who would actually send a bill for balance due, after insurance is paid. They’re the ones who need to straighten this out in their own accounting records.
They did straighten it out- by sending me an $800 bill.
They have been mostly helpful so far, but it seems like they outsource their billing and there may not be an easy way to bridge all of these gaps. I’m hoping we can work it out directly, but you only get so many days to appeal a claim so I am hoping to be ready if it comes to that.
I’ve successfully won ever appeal with a medical insurance company. I start off by calling them and very nicely ask what needs to be done for the claim to go through. Asking for instructions on what the doctor’s office has to do and what I need to do. Then I put all this in a letter and fax it to the doctor’s office and let them deal with it to re-submit it. I then monitor the claim and follow it up if needed. Sometimes I ask the doctor’s office to write an additional letter.
I was once treated in ER for something minor when I was new to the area, and then all sorts of bills started coming my way. I got a letter from the insurance company that said they wouldn’t cover my treatment in ER, which is just wrong because right in the policy it said they cover ER. So I called the insurance company expecting to fight with them, and the woman didn’t even let me get to my questions and asked to verify my name and information. She said “That’s all we needed. We will process it”. And they did. Their first line of defense is to reject claims even if they are perfectly valid because there is a percentage of the population they won’t even follow-up on it which is what they are counting on.
So my advice is from personal experience. The people who answer the phone at the insurance company you talk to are like customer service people and they would prefer not to deal with someone screaming at them on the phone. And at the end of the day, it isn’t there money and if you ask them what needs to be done they will tell you. It isn’t a secret what is in the policy or what is covered. Sometimes they classify something as not covered when it is.
The doctor’s office should have experience with the insurance companies and know what needs to be done so they can get paid. But there is no reason not to talk to the insurance company about it.
I know a dermatologist who told me that if he removes a mole for cosmetic reasons during a skin screening that the insurance company won’t cover the entire office visit because they claim the whole thing as cosmetic. So how he works around this, is during the skin screening if you say “Hey, this mole, I don’t like it, I want it removed” he tells you to make a separate appointment on another day so he can remove it and won’t have a problem getting paid for the skin screening with the insurance company.
Don’t let the clock run out. File the appeal immediately and if it turns out, it was a mistake and they need to re-code it, then it will be resolved and the appeal can be terminated. Filing the appeal costs you nothing but the cost of a stamp.
If they billed you for two ultrasounds when only one was done, that is fraud. You call the doctor’s office and tell them you are about to file fraud complaints with the Attorney General and medical board in your state (and/or other pertinent agencies), but you want to give them one last chance to make things right.
This worked for me when I was billed for an office visit with a specialist that I never met or heard of before. Now I work on the business side of an academic medical center, and I can tell you the word “fraud” gets taken seriously. I’m wondering how large this practice is. If it is small, ask to speak with the practice’s head administrator.
This. The “F” word is how you can get things moving with billers who bill incorrectly and don’t want to listen when you call to correct them.
Be nice as pie when you call, but mention that you’ve been trying to work this out, and now you are receiving a bill for a service not provided, and that is fraud. Also mention that you are going to refer this to the insurance company as fraudulent billing if the office does not reverse the charges for the second ultrasound and never send you another bill. And that they have five business days.
Seconding this. File the appeal. The wheels of insurance justice turn slowly, but you need to have that on record. If the issue is already resolved by the time someone gets around to dealing with your appeal, great! But get it filed.
Thirding it. I don’t know that I would immediately start threatening them with fraud charges over what might be a simple mistake, but start the appeal at once.
Whether it is a mistake or not, “bill the patient and see if she pays” is not unheard of as a strategy both for hospitals and for insurance companies.
I worked for a hospital system for many years, and supported their medical records and billing systems, with all the DRGs and HCPCs and CPTs, but it may also be part of the unbundling of services that is used to maximize revenues. Did you get a blood test as part of this? It is possible that the “first trimester screening” is for the blood test that they often do as part of the screening, and the ultrasound was the other part.
Congrats and prayers for the soon-to-be sven-ette.
I guess I should’ve tried screaming, then. I instead politely asked which code the doctor needed to use instead, and they refused to tell me. They said the doctor was the one who had to figure it out and refile the claim.
Which they did, eventually, but the insurance company was no help.
I wish I could say I had a good answer for this, but I don’t know about there being any magically superior wording. I would think (but I don’t claim any expertise in the area) that just putting it clearly and simply in a letter (following any guidelines the insurance company spells out, of course) is enough to preserve your right to continue to fight, which is the most important thing right now.
But maybe someone with more experience than I have can provide you with something more helpful.
This info will vary by state and insurance company, but here goes:
Your first appeal will usually get denied automatically, by an internal review board composed of the insurance company people.
You will have to file a second appeal. This may be reviewed by an external panel of independent people and you may be invited to participate, giving your side of the story and any other info you feel should be considered.
However, in this case, its not a problem with the insurance company. They shouldn’t have to pay for services not rendered. It sounds like a problem, like others have pointed out above, between you and the doctor’s office. I’d bet you would lose a second appeal as well.
Now for the bad advice section: Don’t pay the bill. Tell them to shine. When I was a professional credit underwriter, we pretty much ignored all medical related dings to credit reports.
Is this insurance through your employer? I had a similar problem when my surgeon’s office would code my procedure incorrectly. After many back and forth’s where neither party wanted to step up and fix the problem or even get on the phone with each other (and I was getting $30,000 bills), I had my HR Director call her contact at Blue Cross and got it taken care of.
(As a fabulous fun fact, this was after a breast reduction, and my billing got so screwed up that at one point my surgeon’s office was submitting a claim for reducing three breasts instead of two. Which, understandably, my insurance didn’t cover and so the claim was denied.)