• Page :
  • 1
  • Text Only
Voting History
rated:
I recently had my first physical exam with a new doctor after moving to new york city. My new plan with Aetna should cover all preventive exam and related tests.

My doctor did the routine check up, ask me a few questions about my chronic conditions (I told him I have very mild asthma -- may need to use my inhaler once perhaps in about two years or so). I complained about recent stuffy nose so he referred me to a ENT specialist. After everything was done in the office, he sent me to get some blood work done to check for cholesterol (I am in my early 30s) in the hospital. Nothing out of extraordinary for a physical.

A couple of weeks later I received a $150 bill from the hospital lab that did the cholesterol test. I called Aetna, and apparently they refused payment because the claim was coded for asthma (i.e., "medical" rather than "routine"). I called the doctors office to clarify and basically the receptionist / biller refused to take the asthma code off, and refused to let me talk to my doctor about billing.

I am caught in the middle it seems. I work with several medical doctors. They and I cannot see how cholesterol tests are remotely related to the asthma. Yet I am stuck with this $150 bill.

What can I do?

Member Summary
Most Recent Posts
I try to avoid the medical dragnet as much as possible. Once you're caught in it, you'll be fleeced to death.

whodini (Apr. 28, 2011 @ 12:12a) |

I used to fight medical bills but I've learned that resistance really is futile. You really have no cheaper recourse. Th... (more)

balor124 (Apr. 29, 2011 @ 5:27p) |

Huh? I don't get why you're asking that. He's got insurance that he thought was supposed to pay it. So thats what i... (more)

jerosen (Apr. 29, 2011 @ 6:30p) |

Quick Summary is created and edited by users like you... Add FAQ's, Links and other Relevant Information by clicking the edit button in the lower right hand corner of this message.
  • Also categorized in:
Thanks for visiting FatWallet.com. Join for free to remove this ad.

Call back and get past the secretary. Learn how to deal with gatekeepers. Never take no for an answer from someone who can't say yes.

Or send a letter. Or go in person.

I think you may be screwed. I recalled a conversation with the wife of my family doc a few years ago when I went in for routine physical... she is doing all his paperwork and knows the insurance system inside and out. I remember she told me to come back for blood work and stuff because I also wanted to have him take a look at my sore throat and she told me the insurance will code everyting that day as a visit office and my blood work wont' be covered under my plan's $500/year routine physical. I remember it because that's quite a strange finding.

I'm quite sure it's how insurance co works, not because the doctor's office.

What troubles me is that he sent me to get the blood work done because he said it's part of the routine. I did not have asthma attack when I went to see the doctor -- it was part of he wanting to know my medical history. It's possible that he can bill me for stuffy nose, but he did not treat me for stuffy nose! Heck, since I have chronic asthma, and since I am supposed to check my cholesterol every year, i'll get billed for bood work every single year? The fact that the biller refuse to let me talk to the doctor regarding the billing also smells foul play.

This was at the New York Presbyterian - Columbia. Is there usually patient's advocate or someone I can file an official complaint?


ZenNUTS said:   I think you may be screwed. I recalled a conversation with the wife of my family doc a few years ago when I went in for routine physical... she is doing all his paperwork and knows the insurance system inside and out. I remember she told me to come back for blood work and stuff because I also wanted to have him take a look at my sore throat and she told me the insurance will code everyting that day as a visit office and my blood work wont' be covered under my plan's $500/year routine physical. I remember it because that's quite a strange finding.

I'm quite sure it's how insurance co works, not because the doctor's office.

signmemama said:   What troubles me is that he sent me to get the blood work done because he said it's part of the routine. I did not have asthma attack when I went to see the doctor -- it was part of he wanting to know my medical history. It's possible that he can bill me for stuffy nose, but he did not treat me for stuffy nose! Heck, since I have chronic asthma, and since I am supposed to check my cholesterol every year, i'll get billed for bood work every single year? The fact that the biller refuse to let me talk to the doctor regarding the billing also smells foul play.

This was at the New York Presbyterian - Columbia. Is there usually patient's advocate or someone I can file an official complaint?

If only there were some mechanism to search the interwebs to find out. Oh well, I guess you'll never know.

http://www.google.com/search?q=new+york+presbyterian+patient+ser...

http://nyp.org/patients/patient-relations.html

PATIENT RELATIONS
NEWYORK-PRESBYTERIAN/
Columbia
(212) 305-5904

signmemama said:   I recently had my first physical exam with a new doctor after moving to new york city. My new plan with Aetna should cover all preventive exam and related tests.

My doctor did the routine check up, ask me a few questions about my chronic conditions (I told him I have very mild asthma -- may need to use my inhaler once perhaps in about two years or so). I complained about recent stuffy nose so he referred me to a ENT specialist. After everything was done in the office, he sent me to get some blood work done to check for cholesterol (I am in my early 30s) in the hospital. Nothing out of extraordinary for a physical.


The highlighted part above is where you went wrong.

What I found out (regarding my insurance) is that if you complain about any health problem during a routine physical, they will bill for that health problem and NOT the physical.

You complained about your asthma which turned it into a treatment visit and not a preventative care visit.

If the doctor's office won't cooperate, call the insurance company back and speak to someone higher on the food chain and tell them that it was a mistake on the part of the doctor's office. I've had success calling my insurance before and having them conference in the billing department at a doctor's office to get messes like this straightened out.

Tell the hospital lab to recode the claim and send it as routine, otherwise it will not be paid.

This happened to a parent who has dementia and a Cadillac Group Health Care Plan through her former Employer.

I called the Insurance first, they told me to call the Billing Dept. at the Medical Office and when I did that I got positive results.

They had billed her $123.00 for a whooping cough vaccine, which was not the reason for the visit.

We went to open the chart because this is a new DR for her new medical insurance plan.

The Dr. suggested the vaccine during the visit...

My belief is that the Health Care Industry is overworked and that is the reason for so many mistakes.

I mean look at the booming Senior Population!

I still have all 4 of my grandparents who are all close to mid 90's and both my parents.

The glossy brochures for my Anthem health plan says that preventive care is covered for free, but.... the fine print concerning preventive care says: "You must be free of any illness or condition". Under Anthem's rules you would not be entitled to any free preventive care.

1. If you are 30 checking cholesterol is a recommended screening test for health maintenance.
2. If you mention asthma and runny nose you essentially need an ENT workup.
3. You physician might not check what insurance you have and/or know what a routine visit is paid differently from a sick visit.
4. Your insurance company is the one who is making up rules not the physician. Your insurance company wants you to go for a well visit separate from a sick visit and will pay the physician either a sick visit or a routine visit. Since sick visits are billed lower than routine they decided to pay the lower amount.
5. By asking the physician to remove the diagnosis you are asking them to comit insurance fraud.

OP,
Your problen is not the hospital.
They bill for your routine lab test based on the ICD code the doctor put on your script.

You want to get a copy of the script you submitted either from the doctor or the hoospital and see what the ICD code is.
You might then have a basis for disputing the bill or a reasonbable basis for asking the doctor to revise the "incorrect" ICD code.
If the purpose of the test was to determine your cholestorol leve then it would NOT be insurance fraud to have the doctor correct ICD code.

As a final thought, if the doctor refuses to talk to you or refuses to provide a reasonable basis for correcting the ICD code then perhaps you should look for another doctor.

Isn't a prescription necessary for an inhaler? If so, then you needed to see someone who could write you that prescription, right? Perhaps your primary physician wasn't comfortable writing a prescription without you seeing an ENT and having a workup done.

Many hospitals have an ombudsman. See if the hospital has one and see if you can speak with this person. Might help cut through some red tape.

I've had Aetna for 10 years. In all my experiences the exam is considered preventative; lab work outside of the exam is not.

Also when you say "not covered", you mean not covered as preventative, and you need to pay it because it applies to your medical deductible?

If the doctor refuses to communicate with you send him a letter notifying him that you will be contacting the medical licensing board and report him.
You'll have to check what the official name of the NYC licensing board is so you can use the correct name in your letter.

I don't know if the licensing board will even do anything, but it might get the doctor's attention and allow you to rectify this situation.

As I said in a post above, if it were me, I would look for another doctor.
You said you work with a number of doctors, perhaps they could recommend someone.

Also, what is wrong with paying more than what your insurance will cover for out of your pocket? Why wouldn't you spend for your own health?

IQ70 said:   Also, what is wrong with paying more than what your insurance will cover for out of your pocket? Why wouldn't you spend for your own health?The issue isn't paying more than your insurance will cover.
The issue is paying out of pocket for items that you thought your insurance should cover.

In the OP's case it appears he is being charged for a lab test that the doctor coded incorrectly.
As was mentioned previously a cholestorol test is not related in any way to asthma diagnosis, prevention or treatment.

mikeres said:   IQ70 said:   Also, what is wrong with paying more than what your insurance will cover for out of your pocket? Why wouldn't you spend for your own health?The issue isn't paying more than your insurance will cover.
The issue is paying out of pocket for items that you thought your insurance should cover.

In the OP's case it appears he is being charged for a lab test that the doctor coded incorrectly.
As was mentioned previously a cholestorol test is not related in any way to asthma diagnosis, prevention or treatment.


1. You cannot write a script for "cholesterol" with a diagnosis of "asthma". The lab wont do it.
2. OPs issue is that she/he got billed for a lab and he doesn't know why. He wants the "asthma" diagnosis removed not from the lab slip but from the records since the visit is being billed as insurance for a "sick visit" which pays less and hence the choice for the insurance company.
3. Since the insurance company wants to bill the visit as a "sick visit" and not pay the physician the higher amount of a "routine visit" they also screwed OP over by denying the claim for the accompanying blood work done on the same day.
4. This is why your physician might tell you to make separate appointments for different issues and a lot of patients get mad at them since they assume the physician is trying to make more money off them.


Sick Visit = $109 for private insurance for a new patient. Might be as low as $25 for "in-network"
Annual Exam = $140 for private insurance for a new patient. Might be as low as $40 for "in-network"

So since OP mentioned runny nose, the insurance company wants to pay less to both the physician and OP as reimbursement/benefits.
Simple game insurance company plays.

IQ70 said:   mikeres said:   IQ70 said:   Also, what is wrong with paying more than what your insurance will cover for out of your pocket? Why wouldn't you spend for your own health?The issue isn't paying more than your insurance will cover.
The issue is paying out of pocket for items that you thought your insurance should cover.

In the OP's case it appears he is being charged for a lab test that the doctor coded incorrectly.
As was mentioned previously a cholestorol test is not related in any way to asthma diagnosis, prevention or treatment.


1. You cannot write a script for "cholesterol" with a diagnosis of "asthma". The lab wont do it.
2. OPs issue is that she/he got billed for a lab and he doesn't know why. He wants the "asthma" diagnosis removed not from the lab slip but from the records since the visit is being billed as insurance for a "sick visit" which pays less and hence the choice for the insurance company.
3. Since the insurance company wants to bill the visit as a "sick visit" and not pay the physician the higher amount of a "routine visit" they also screwed OP over by denying the claim for the accompanying blood work done on the same day.
4. This is why your physician might tell you to make separate appointments for different issues and a lot of patients get mad at them since they assume the physician is trying to make more money off them.


Sick Visit = $109 for private insurance for a new patient. Might be as low as $25 for "in-network"
Annual Exam = $140 for private insurance for a new patient. Might be as low as $40 for "in-network"

So since OP mentioned runny nose, the insurance company wants to pay less to both the physician and OP as reimbursement/benefits.
Simple game insurance company plays.
What you're saying, I suspect, is much closer to what is happening.
My bad for not properly understanding and for offering inaccurate/inappropriate advice.

In order to avoid being billed for lab tests that should be considered part of preventive care, I make sure that my blood work is done on the same day of my physical and I try to confirm that no diagnosis code is being entered. My PCP's (primary care physician's) office likes to schedule blood work a few days before annual physicals so that the Dr. can review the results on the day of the physical. Although there are clear advantages to this approach, whenever I try this I get billed for the lab tests. It usually takes several calls to get the tests coded correctly. In contrast, if blood is taken during the physical, I never have a problem.

Once something is submitted under a certain code, it is very difficult to correct. The lab and insurance company understandably rely on the doctor's assessment and are likely to refer you to your doctor's office. The doctor's office may assume you are mistaken or be reluctant to bother the doctor. In addition, the billing department may not want to spend the time correcting paperwork that in some cases will result in a lower reimbursement.

We were once billed for a x-ray that was never taken. It was amazing how many phone calls it took to get the bill corrected.

I am having the same problem with Anthem. 10yrs ago I was "diagnosed" with high Cholesterol found in a blood test tied to a "routine" exam and for the last 9yrs my Dr has coded it as a "diagnosis" and this year Anthem won't cover the annual blood test...since its a "diagnosis". My question is when does the "diagnosis" expire and it goes back to a routine exam?

Only positive is Anthem's agreement has the $250 blood test negotiated down to $35...but it should be $0.

Never?
New laws prevent pre-existing conditions clause. Hence insurance companies have a new way of not paying for them.

What's wrong with paying for your own health from your pocket?

IQ70 said:   Never?
New laws prevent pre-existing conditions clause. Hence insurance companies have a new way of not paying for them.

What's wrong with paying for your own health from your pocket?


I am, I paid my $25 co-pay which has covered this song and dance for the last 10 yrs (used to be $15 not too long ago). Also my monthly premium doubled from '10 to '11, so I am paying - paying dearly.

I try to avoid the medical dragnet as much as possible. Once you're caught in it, you'll be fleeced to death.

I used to fight medical bills but I've learned that resistance really is futile. You really have no cheaper recourse. They come you pay.

IQ70 said:   
What's wrong with paying for your own health from your pocket?


Huh? I don't get why you're asking that. He's got insurance that he thought was supposed to pay it. So thats what is wrong with him paying for it. The insurance was supposed to.



Disclaimer: By providing links to other sites, FatWallet.com does not guarantee, approve or endorse the information or products available at these sites, nor does a link indicate any association with or endorsement by the linked site to FatWallet.com.

Thanks for visiting FatWallet.com. Join for free to remove this ad.

TRUSTe online privacy certification

While FatWallet makes every effort to post correct information, offers are subject to change without notice.
Some exclusions may apply based upon merchant policies.
© 1999-2014