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Can I do anything about this?

Discussion in 'Topics in Healthcare' started by baylormed, Feb 21, 2007.

  1. baylormed

    baylormed On the Search
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    My student insurance, which clearly states on the forms I got will cover 80% of doctor's visits, just returned a bill from my ENT's office saying that "consultations" are not covered by my plan. I had a freaking referral from my undergrad's health center, too, it's not like I just like to visit the ENT for fun.

    It's not such cheap insurance, either. I give up, I refuse to give more money to insurance companies, I'll set up an account exclusively for medical expenses and ask for family donations if more is necessary. God, I'm mad. :mad:
     
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  2. resxn

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    That serously sucks. How can they not cover consultations when it was referred by your PCP? That is one of the worst insurance plans of which I've ever heard and I'm ENT. It's definitely the worst I've seen for a med student.

    You should be mad.

    One option is to see if the doc will recode it to "new outpt visit" rather than "consultation" which may help. Or even better if he waives the fee in lieu of professional courtesy.
     
  3. OP
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    baylormed

    baylormed On the Search
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    I will definitely try your suggestion. I've also been calling the insurance company but I get put on hold and I listen to music for ~10 minutes and then the line just gets cut off. I'm going to see what else I can do.

    I'm even more mad because I've been paying for it and this is the very first time I use it. Oh yeah, and the "consultation" with the EMT lasted less than 10 minutes.
     
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  4. DoulaMD

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    I would definatly contact the insurance company to see what the denial code on the claim is. Sometime the insurance has a website where you can look it up. See if the claim is denying for CPT or DX code or other. Often times claims get denied for having an extra DX code on it. (example- women goes to see OB/GYN for annual check up and dr asks how her sex life is, women says its ok but could be better. Then the dr continues with check up and their is no further discussion about the paitents sex life. Dr puts Sexual Dysfunction code on claim and it gets denied as not a covered benefit.) Some times things get rejected for the smallest things. Find out why it rejected first then appeal or have provider submit a corrected claim with corrected codes if needed.
     
  5. docB

    docB Chronically painful
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    A lot of insurance companies just reject ~10% of all claims hoping the insured just pays it and it goes away. I won't name names here but it's worth fighting. I still give you a 50-50 chance of getting stuck with this and being made permanently bitter toward insurance companies. In that respect it's good that it happened so early. Just think of it as part of your medical education.
     
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  6. Blue Dog

    Blue Dog Fides et ratio.
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    Not likely. An office visit charge may be denied if the primary diagnosis isn't covered, but it wouldn't be denied based on any additional non-covered diagnoses.
     
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  7. DoulaMD

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    Actually I have worked for two healh insurance companies in the past and they will reject a claim if even one diagnosis is non covered, primary or not. Believe me I know all the things that can screw up claims and fortunatly the way around a lot of them. First thing to find out is what rejection code the insurance kicked it out for and then go from there. If you have any insurance specific question feel free to ask me.

    PS- I love Scrubs! Love your siggy :)
     
  8. OP
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    baylormed

    baylormed On the Search
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    The rejection code was ZU.

    Could you please tell me more about that? I'd really appreciate any help I can get. :(

    Thank you!!
     
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  9. DoulaMD

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    What was the description of the rejection code ZU? The codes vary from insurance to insurance and I don't know that one?
     
  10. OP
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    baylormed

    baylormed On the Search
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    It says:

    ZU: This type of service is not covered by your plan. Please see schedule of medical expense benefits. There is no benefit for consultations.
     
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  11. sdn1977

    sdn1977 Senior Member
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    So....from what you're describing, you have basically a major medical plan - it covers the big stuff - trauma, heart attacks, strokes, emergent appendectomies....

    Call them & find out what your limitations are. It should say on your paperwork that it will cover 80% of "plan physician visits" - which is another way of saying only those folks who've enrolled in our plan - which may be no specialists.

    The only way to know is to have your documents in front of you, your EOB & a phone call to their customer service number.
     
  12. typeB-md

    typeB-md Be more like McCain!
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    this is seriously ridiculous what insurance companies do. can't doctors just band together and decide to reject all insurance and just start accepting cash payments on par with what insurance would've payed them?
     
  13. docB

    docB Chronically painful
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    No. We can't even get docs to quit testifying against other docs as plaintiff's "experts."
     
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  14. DoulaMD

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    Yeah it sounds like your plan covers major medical charges only:( . The best way to see what your plan would cover is to get a copy of your EOC-Evidance Of Coverage booklet. That booklet list out all of the benefits and exclusions. If you don't have minor medical coverage than I think you are right to think about setting up a bank account for medical charges that you might need. Also find out if you are offered an FSA (flex spending account) or something similar. It is basicly the same thing an account you can use for medical expenses but it is tax free.
     
  15. sdn1977

    sdn1977 Senior Member
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    hmmmm....I thought we had a thread on here a bit ago about the "boutique" practices. I've got 2 in my area that have gone this way & I just heard about 1 Ob-gyn who has done it as well.

    Still watching & waiting.....I've yet to see a current pt of theirs come in with an rx, but the pts of theirs who used to see them have now had most all rxs transferred to different physicians since we're nearly one quarter into the new year.
     
  16. Kateb4

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    Hey, another thought. I recently saw an ENT for some sinus problems, and also for allergy testing. My school plan does not cover allergy testing, therefore none of those claims were paid (thank god my school plan is only my secondary). They did cover the sinus problems, so I'd go thru your Certificate of Insurance/Plan Benefits booklet and look for the exclusions. Your policy probably has an exclusion for the particular dx code that they used on the claim. If you can't find anything, call the ins co and make sure that they send you a copy of the certificate that describes the exclusion if that is the case, because sometimes they make mistakes too (sometimes - ha!!!)
     
  17. OP
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    baylormed

    baylormed On the Search
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    I called the insurance company and they said in fact, my plan covers doctor's visits but not "consultations" (when a doctor refers you to another doctor). In other words, I need to walk into the office unnanounced and dying, and maybe they'll cover it.

    I called the doctor's office and they said that in fact, it had been coded as a consultation, and that No, they cannot change the codes because it would be considered fraud.

    I'll just have to suck it up and pay for it, they said they'll give me an ok discount if I pay it all cash and upfront.

    Bla. I'm sad. :(
     
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