asking providers to change codes?

[SparklyUnicorn]

I looked through my benefits because the insurance company claimed ophthalmology is only covered once a year.  Nowhere does it say that except for certain screenings.  So the code they billed does not describe a screening either.  It's just an ophthalmology office visit code.  (92012 if you happen to know about coding)  So I asked the insurance company where in the benefits it says this won't be covered.  Oh it doesn't, but that is how it comes up when it is billed.  That it is only covered once a year.  Uhhh...so how would I have known about this, and what should I do?  I should call the provider.  And do what?  Oh I don't know...maybe ask them to use another code.  Ok.  So I'll try that.  I think this is absolute bogus bull turkey.  But I will.  I have to call tomorrow because they are closed for the day.

 

I'm going to ride both of them until they fix this because I need to go back there and probably pretty regularly.  They have me using steroid eye drops for allergies and that has to be monitored because they aren't really safe and only used as a last resort.

 

Has anyone done this?  Called the provider to ask them to bill something else?  Did that actually work?

 

I'm so annoyed.  :glare:

[FaithManor]

I looked through my benefits because the insurance company claimed ophthalmology is only covered once a year. Nowhere does it say that except for certain screenings. So the code they billed does not describe a screening either. It's just an ophthalmology office visit code. (92012 if you happen to know about coding) So I asked the insurance company where in the benefits it says this won't be covered. Oh it doesn't, but that is how it comes up when it is billed. That it is only covered once a year. Uhhh...so how would I have known about this, and what should I do? I should call the provider. And do what? Oh I don't know...maybe ask them to use another code. Ok. So I'll try that. I think this is absolute bogus bull turkey. But I will. I have to call tomorrow because they are closed for the day.

 

I'm going to ride both of them until they fix this because I need to go back there and probably pretty regularly. They have me using steroid eye drops for allergies and that has to be monitored because they aren't really safe and only used as a last resort.

 

Has anyone done this? Called the provider to ask them to bill something else? Did that actually work?

 

I'm so annoyed. :glare:

Yes, I have had to do this before. I tend to be friendly, but firm that the code needs to be changed because my insurance is infested with angry, unhelpful humans, they will usually look to see what they could ethically put it down under so it will get paid. I think it is hard for them to keep the codes straight for so many insurance companies. Annoying yes, but worth the phone call.

 

Sometimes too we have to call and remind them that any visits for my ankle or near, or ds's leg must be billed to car insurance as well. They have it in the system, but sometimes it gets overlooked and well, it is better to do gentle reminding than get into it with the provider's billing agent or the insurance company who will do everything in their power to prevent me from trying to find out how to get it paid.

 

I envy my sister in France. She doesn't have to deal with this crap, and sees whatever doctor she needs whenever she needs to no questions. Sigh....

[SparklyUnicorn]

Ok good.  So annoying to feel caught in the middle of these ridiculous games.

 

 

[Crimson Wife]

Has anyone done this?  Called the provider to ask them to bill something else?  Did that actually work?

 

Yes, so long as it is something that can be medically justified and not seen as fraud.

 

Under the policy we had through July, my daughter's speech therapy was covered if the provider coded it as being to treat autism (since the policy was subject to the state autism mandate) but not to treat hearing loss. The treatment is the same and there is no way to tease out how much of the speech & language delay is due to the autism vs. the hearing impairment. So it doesn't matter from a medical standpoint which code gets put on the bill. But from an insurance standpoint it absolutely matters.

 

The clinic where my daughter receives therapy specializes in working with patients with hearing loss so their default coding is hearing loss. But when our insurance denied the bill, they changed the coding to say autism so that the policy would cover it.

 

If some outside auditor were to question the coding change, the clinic could make a totally legitimate case since my child has both conditions. It's not like they are fraudulently claiming "autism" without having the diagnosis to back up the code. 

 

[G5052]

Sometimes even rearranging the codes if there are several makes a difference.

 

We learned this with an ER visit. There were psych issues among other things, and when they put the psych code last -- it was paid!

[Ali in OR]

I did this once with my primary care over bloodwork. My insurance would cover it if it was part of routine well-patient screening (I can't remember details). There was no other reason I was having the bloodwork done, so I called my doctor's office and they changed how it was coded. Doctors' offices like getting paid; they have to be pretty good at working with the insurance companies and jumping through their hoops. I imagine most deal with this on daily basis.

[Rebel Yell]

I once had vision insurance that only covered exams every two years, even for children with glasses and eye problems. Because of the type of eye Dr. I go to (sorry, not sure the difference) we could get the exact same exam covered under a medical reason IF there were medical problems, such as headaches. Magically, new glasses were covered (up to a certain dolllar amount) every year for medical reasons like headaches, but only every other year for silly things like a change in prescription. :rolleyes:

[Lanny]

I think if you call the Provider and ask to speak with the Insurance person, that if you ask nicely, for them to please look for a Code that your Insurance company won't reject automatically, and tell them that you will greatly appreciate that, they may help you out and do that for you.

 

I remember when I lived in TX, my primary doctor (Cardiologist) had about 6 or 7 people working for him. One of them did NOTHING but Insurance forms.  If you wonder about what they charge for an office visit, one big reason is because their Overhead is so high. And another reason is what they pay for Malpractice Insurance.  

 

Good luck with them finding a better Code to submit to your insurance company!

[Annie G]

We've had to request that they review how they coded something and they have always been able to change it for us. They want to get paid, so they're usually willing to see if what they did might fall under another code.  Nothing unethical, just paperwork details. It's worth a shot- hope they can help you. 

[Homebody2]

I have had to do this at least 5 times. Don't be surprised if you have to go back and forth between the doctor and the insurance company a few times. Be polite, yet firm, and advocate for yourself.

 

I got so frustrated at one time that I called the CFO of the hospital. You better believe I got results after that! The VP of the revenue cycle knows me by my first name.

 

Edited to add that in all the cases, it was the provider that had to resubmit the claims with a different code. Our insurance couldn't change a thing until that was done.

Edited August 30, 2017 by Homebody2

[Nicholas_mom]

We ask our insurance what the code should be to be covered for the services, then we tell our provider.  He is very accommodating and if it is a code not covered will ask me what code it should be.

 

It really should NOT be a problem.  It is done all. the. time.  If you ever go into a doc's office In-network provider and they take care of the insurance for you and a code does not work, the doc's office will fix it to code it so the Doc's office gets paid.

[ashfern]

We've had to do that with our dental office. One time it was for my crown. My insurance only pays for a metal one unless it's on a front tooth. I paid the difference but they submitted it wrong. The insurance company rep said to have it redone with a metal crown and they would pay.  :confused1:  Seriously, who would have a new crown taken out for that. Plus, I would still owe the dentist for the first crown. I talked to billing and they first insisted that I needed to pay the difference. I told them that I already had and that they needed to submit it correctly to get paid. I never heard anything back about it. I will say that if my dentist makes another billing error that we will find a new dentist. The billing department is really rude!