Health insurance question?

Question

I have never dealt with health insurance before, sorry if my question is silly.

My health insurance ( NJ Horizon Blue Cross) covers prenatal care, including ultrasounds and blood work.

My doctor's office keeps on billing me for an ultrasound that supposed to be covered.

I've got the same bill about 4 times. When I call my insurance agency, they say that my ultrasound is completely covered, but doctor's office should use another code to fill in the claim.

I asked the office to change the code many times, but I still do not get coverage.

Is there anything I can do? I feel like I am going in circles. Who can really resolve this problem, doctor's office or insurance agency?

Thank you Doug,

Sorry, I was not clear before, but I dealt with Horizon directly too. I did bring the paper that explains my responsibilities to the medical biller. Horizon even gave her customer number to call in order to change the code. She filed claim again, and it did not get covered again.

Answer 1

If your insurance company has received this claim and processed it then the charge is either covered or denied. It sounds like they denied the charge due to the CPT (current procedural code) being either invalid or possibly not matching the diagnosis code. Regardless of why it was denied you should not be stuck in the middle. Your doctors office should be working with your insurance company to correct this. You should have received an EOB (explanation of benefit...says "this is not a bill") and it will say on the EOB what the patient is responsible for. Many times your insurance company will deny the charge due to coding errors however it will say the member responsibility is zero. That means the provider cannot balance bill you for this. If the provider is a participating provider than it is more likely that you should not be billed. Contact your insurance company and demand that they do a three way call to the doctors office and get it resolved right away. If the insurance company says they cannot contact the provider, than ask to speak to a supervisor. They have to work with you to resolve this. I have been in the health insurance business for 12 years and I deal with this all the time and it usually is a matter of the providers office rebilling to correct it. Whatever you do, dont pay for this as long as the denial remains a coding error. CPT codes are often updated yearly and many times the providers office is not aware of this and they bill with a deleted code. There is no reason why your plan would not cover an ultra sound and you may just have to be more persistent in getting it taken care of. Good Luck!

Answer 2

Unfortunately, yes... the clinic is the one that needs to use the correct coding to furnish to the insurance company.

You can find out what the codes are that are covered by calling and talking to the claims customer service number (not all insurance companies are the same... some may not disclose this while others will). Then you can pass the "CPT" codes on to the biller at the clinic.

As it stands, it's the clinic that needs to make the correction. If the codes they are sending do not match up with what is allowed on the contract, then the insurance company is going to look at it as out of network or not covered.

Another thing you could do, if this doesn't resolve... talk to your Human Resources person in charge of the health insurance. Have him/her contact the Agent and have the agent work on it. This is part of their job for servicing the group.

The agent will in turn go to their contact at the insurance company and work out resolution.

Answer 3

Blue Cross should have sent you a bill, that included how much the doctor's office charged, how much was the negotiated rate (what the contract with the doctor's office allows to be charged), what was deducted as being over-billed per the contract, and what your responsible portion is.
Try speaking with the Office Manager for the doctor's office, explaining what you are going through. Call Blue Cross and ask for a copy of the EOB (explanation of benefits) that Blue Cross would send to you explaining what I've outlined in the first paragraph.
The insurance agency has nothing to do with this transaction. They only sell you the policy; you have to call Customer Service with Blue Cross. The insurance agency will tell you whatever they have to in order to get you off of the phone.

Answer 4

I recommend you to visit this web page where you can compare quotes from different companies: http://insuranceforcheap.info/index.html?src=2YAGBbLBp0IMV

RE :Health insurance question?
I have never dealt with health insurance before, sorry if my question is silly.

My health insurance ( NJ Horizon Blue Cross) covers prenatal care, including ultrasounds and blood work.

My doctor's office keeps on billing me for an ultrasound that supposed to be covered.

I've got the same bill about 4 times. When I call my insurance agency, they say that my ultrasound is completely covered, but doctor's office should use another code to fill in the claim.

I asked the office to change the code many times, but I still do not get coverage.

Is there anything I can do? I feel like I am going in circles. Who can really resolve this problem, doctor's office or insurance agency?
Update: Thank you Doug,

Sorry, I was not clear before, but I dealt with Horizon directly too. I did bring the paper that explains my responsibilities to the medical biller. Horizon even gave her customer number to call in order to change the code. She filed claim again, and it did not get covered again.
Follow 9 answers

Answer 5

Many companies require for you to get your policy at least a year (depends can be 10 months or more) before you actually get pregnant. If you get your policy and immediately get pregnant, the insurance company does not cover the costs of prenatal care. Some companies cover the actual birth and not prenatal care if you get the policy and then get pregnant 3 months after. Check this clause in your policy (yes this actually means you have to read that boring policy).
If you have a broker/agent he/she should explain you more about your policy and be the mediator between you and the company (hey thats why we make commission right?)
In case you don't ask the insurance company to send you the form your doctor is supposed to fill out and give it yourself to the doctor. Companies are very specific on their forms to fill, he might be filling the wrong code
Hope this helps out :)

Answer 6

In my experience, you're supposed to deal with your insurance agent and if they still bill you, then you need to make a ruckus and write letters of complaint, etc. You already did your due diligence in this matter, and it should be the insurance agency's responsibility to call the doc's office and get the right code or forms, not yours. So make a scene, threaten a lawsuit, and they will stop bothering you.

Answer 7

Ask the insurance company what is the correct code, then call the doctor's office and give them the code. If that fails, ask your insurance company to do a conference call with you, them, and the doctor's billing staff to get the problem resolved.

Answer 8

The insurance company can't disclose the "code". Which code is wrong? The diagnosis code? The procedure code? What is wrong with it? Is it causing your ultrasound to be applied to your deductible? Is it being denied completely?

Appeal with your insurance & beg your doctor's office.

Answer 9

I suggest that you visit this site where onel can compare quotes from different companies: http://HELP-INSURE.NET/index.html?src=5YAqqC1AOR8gjm1

RE :Health insurance question?
I have never dealt with health insurance before, sorry if my question is silly.

My health insurance ( NJ Horizon Blue Cross) covers prenatal care, including ultrasounds and blood work.

My doctor's office keeps on billing me for an ultrasound that supposed to be covered.

I've got the same bill about 4 times. When I call my insurance agency, they say that my ultrasound is completely covered, but doctor's office should use another code to fill in the claim.

I asked the office to change the code many times, but I still do not get coverage.

Is there anything I can do? I feel like I am going in circles. Who can really resolve this problem, doctor's office or insurance agency?
Update: Thank you Doug,

Sorry, I was not clear before, but I dealt with Horizon directly too. I did bring the paper that explains my responsibilities to the medical biller. Horizon even gave her customer number to call in order to change the code. She filed claim again, and it did not get covered again.
Follow 10 answers

Answer 10

Ask your insurance company to send you a letter and to cc: it to the dr's office explaining it is covered.