Image courtesy of phasinphoto at FreeDigitalPhotos.net
I shook up our family’s medical insurance this year. Instead of signing up for the traditional low deductible PPO (Preferred Provider Organization) as I had for over 10 years, this year I selected a high deductible PPO with a Health Savings Account. I knew things would take a little getting used to, but I never thought that one little sentence would end up costing us over $600.
One major difference between our old plan and our new high deductible PPO is what services are paid for out of pocket before the deductible is met. With our old plan, all preventative services as well as office visits when someone is ill were all covered 100%. With our new plan, preventative plans are still covered but office visits are paid for out of pocket until the deductible is satisfied.
My wife recently asked me to explain again how our new insurance plan worked, as she was due for her yearly physical exam and wanted to prevent racking up out of pocket expenses if possible. I showed her the documentation that explained that a yearly physical would be classified as preventative care, and therefore would be covered 100%, with no out of pocket expenses for us.
When we got our explanation of benefits statement, something didn’t add up.
Her doctor’s visit was NOT classified as preventative care, nor was the blood work that was done to check things such as her cholesterol level. We immediately called our insurance company, who of course shifted the blame to our medical provider for the code they assigned to the visit and the blood work. We then called our medical provider to find out how they classified her visit, and why. The code on file was, “Dizziness and/or Giddiness.”
My wife admitted that when asked during the exam how she had been feeling, she had replied, “Sometimes I feel a little dizzy, and cannot explain why.” The doctor made the comment that if the blood work she was going to have done anyway did not reveal anything, they may have to look deeper if my wife was concerned about the dizziness.
Unfortunately, that short statement had expensive consequences.
Because my wife’s statement was written in the doctor’s notes, that became the basis for the coding assigned to the procedure. That short sentence was enough to convert my wife’s physical exam to an office visit, and her routine blood work up just to check things out into one that was looking for a reason for a symptom.
In the eyes of our medical provider, my wife was no longer there for preventative care, but was there for an office visit to discuss a symptom. More importantly, it meant that the office visit now cost us $315 out of pocket, and the blood work just over $350.
Under our old insurance plan, it wouldn’t have mattered as both preventative and office visits were covered 100%. We wouldn’t have even noticed how the visit to the doctor had been classified because our bill would have been zero. No reason to question a bill of $0.
Our experience taught us three important lessons:
- Ask Questions: Even at the time of making the appointment, ask questions. If whomever you’re talking to doesn’t know, call the billing department and talk to whomever does. Someone knows how your visit will be classified,and if they say otherwise, they’re LYING.
- Become Familiar with the Codes: Ask your insurance company AND your medical provider what code is assigned to routine preventative physical exams. Know what code you want.
- Don’t Offer Extra Information: Next time one of us is in for a routine physical, we’ll simply request services that will give us a complete checkup. If we’re tempted to tell the doctor about any concerns we have, we’ll first ask the doctor if giving any additional information would cause my visit to be classified anything other than the code I was given from #2.
Medical care shouldn’t be this confusing. One of the problems is that the medical personal that are in charge of giving us medical care, also wield the power to determine how much we pay. The only way consumers can get the full coverage that we should from our medical plans is for us to become educated, ask questions, and guide our medical providers to use codes that are appropriate.
Have you ever had a surprise when you opened an explanation of benefits? What did you do about it?
Oh man, sorry to hear about that Travis. We’ve had something very similar happen to us a couple of times and was a headache both times to get straightened out. So, my wife started calling beforehand trying to figure out what we’d be charged for something or how it would be coded and that’s even worse. It just shouldn’t be that difficult. The worse time though was when charges for my son (he’s a III and I’m a Jr.) were charged against me. It was an absolute cluster to say the least.
I can imagine that would be a nightmare, John. The thing is, it shouldn’t be THAT hard to explain and get corrected. But I bet it took months of time and multiple phone calls……
I found this out the hard way as well. My insurance covers dental cleanings as preventative care, but I had to go in for a non-routine checkup for my fillings. As I was checking out, I found out most insurance companies don’t cover this type of visit. It would have been nice to know that ahead of time! I might have been able to push it off until my semi-annual cleaning in a few months. In the end I was only out $100 but it still stung.
It’s silly that it’s come to this, Jon, but it’s almost like you have build a treatment plan, ensure that it’s going to be coded correctly BEFORE going in for care. Then, if the doctor wants to do something off the plan, then more investigation needs to be done on the fly. it’s the ONLY way we can know for sure that things will be covered!
I feel your pain. Our medical insurance surprise cost a whopping $1,500. My wife was getting regular monthly infusions which cost us a $125 co-pay each. When the calendar year changed, even though she was on the same insurance plan, they changed it from a co-pay to a % co-insurance and we didn’t notice. Three months later, we finally received the EOB’s showing a co-insurance of $625 per visit. Whenever there are changes to your insurance plan, read ALL the fine print carefully and be sure you know how the changes will apply to you. Even though we’re normally on top of these things, this time it slipped by but you can be sure we won’t let that happen again!
Yikes, Gary, that’s a significant change year to year in your policy. Your situation is a good example of why we need to examine the details of our coverage every year – even if they say the plan is the same, it may not be!
What a pain, Travis. It’s so not right that we have to become experts on medical billing these days. And I hate the thought that simply saying, “I get dizzy” can lead to a big bill. It’s going to stop people from sharing, which isn’t good either.
I agree, Shannon…we shouldn’t have to play a game to get good medical treatment and get the most coverage from our insurance as possible. Our health care system is SO broken.
Ugh, what a pain. We pore over our health insurance manual and call before every procedure, but what’s so frustrating is that they often don’t know the answers to our questions, which is not very reassuring! I’m grateful to have insurance, but I wish the explanations of benefits were more straightforward.
It is a pain, and them not knowing what they will code the visit at is complete BS. Why would they NOT know what they would code it at. From now own, I will pester them until they give me an answer – along with their name. Then, when I go to the doctor, I will tell the doc that I need them to tell me if they’re going to do anything that would cause any other code to be associated with my visit – as further assessment will be needed before they will be allowed to do those procedures. I may be a complete pain in the ass, but I will not get another surprise medical bill!
The doctor might have thought he/she was being helpful. Some insurance plans don’t like to cover general visits. My mom went in once for a physical, and the doctor asked her what some reasons might be that she was there. She ran through a few til Mom agreed that one kinda sorta applied. That became the reason for the visit because the doctor wanted to be sure it was classified as necessary.
In this case, it seems like the inverse happened, which sucks. I guess insurance headaches never end.
The doctor should have communicated her “helpfulness” to us, Abigail. You’re right that the inverse occurred here….which is why it’s important to be proactive instead of reactive. just going into the doctor’s office and hoping for the best just doesn’t cut it anymore.
Yes I had this happen too. I went in for a routine physical but had mentioned that I had gotten one or two ocular migraines once or twice that previous year and my doctor took notes. She gave me a free sample of medication, which by the way I never touched, and I get getting huge bills for my “migraines” from my health insurance. It was a year long pain in the ass battle, with all kinds of sketchy behavior from my insurance company, but in the end I was persistent and I won. Now when I got to my doctor, I asks just as many questions about billing as I do anything health related. I flat out tell my doctor that I’m on a very tight budget and I need to know what is exactly going on her notes for our appointment. It sucks that it has to be that way, but better than dealing with the headache of the insurance company.
After what we just went through, your story (unfortunately) doesn’t surprise me. It’s time to be proactive with our medical care…I don’t care how much my medical provider hates me – if they’re going to code things this stupidly, then I’m going to take every precaution to make sure it doesn’t happen again.
Insurance can be costly. I was referred by a in-network doctor, to a not in network doctor. WOW, big bucks. But I guess they do not know all about your own plan.
Ah, another caveat of medical care – referrals! When are they allowed, when are they not, what will it cost you. Really, it shouldn’t be that hard. Every time I’ve been referred to another doctor or to a specialist, I immediately call my insurance to find out how it works – or even to double check how I understand it. Thanks for sharing!
I had that same thing happen when I went in for a physical and talked to the doctor about possibly getting a Xanax for a long flight I was nervous about. We decided against it and I didn’t get any prescriptions, but my visit got coded as Other Fear/Phobia instead of routine visit. The billers were no help, and then I asked them to ask the provider if she intended it as a problem visit or routine. The provider then changed the primary code and they billed it correctly.
Providers have to record what you say, and it’s sad that makes it mean people won’t mention things that are bothering them. I guess the question is, would Vonnie have gone in for the dizziness or was it not a big deal? If it wasn’t a big deal, I’d ask the provider to review it. It might not help, but it did in my case.
Unfortunately, we did request a review, stating that the visit was intended to be a yearly physical exam. The billing people came back with “no change recommended.” I have something I’d like to recommend for them……lol.
I think the suggestion is to have the physician (provider) review and correct the code for the visit (not the billing department).
My husband traveled to the U.S. for a business trip, and while he was away – 12 hours before his flight home – he suffered a gallbladder attack. A colleague took him to the nearest hospital, and he was drugged up (in the best possible way) and then allowed to go to the airport in time for his flight. He had to pay $2,500 as a “deposit” for the hospital service! And when the full bill came in, it was for over $6,000. Yikes! It took a while to sort it out, but my out-of-country plan through work covered it. Phew! That was 3 months after we had started our journey out of debt. Sometimes I get annoyed with high Canadian taxes, but this kind of post makes me appreciate the fact that our taxes are covering free medical care. That’s a pretty frustrating event for you and Vonnie, Travis. But you’re moving forward with a good strategy.
Oh boy…out of country – I can’t even imagine what kind of an obstacle course my insurance company would have in store for me if I had that situation!
What? This seems super shady. Were you able to correct/fight this?
I agree, Stefanie – we requested that they review the coding stating that the intent was for the visit to be a yearly physical exam. Their “official findings” was to recommend no change. ugh.
I had a similar situation several years ago (but not so costly). Basically, the doc could classify my visit according to preventative care or give me a diagnosis (something like allergies). From what I could discern, either would have been a legitimate coding. But he went with the diagnosis, thinking that having an actual illness would involve insurance covering the visit, when in reality the opposite was true. So, my next step involved educating my physician on my insurance coverage so his coding could be accurate and legitimate, plus cover the service provided.
One would think physicians would know this too, wouldn’t you? But yeah, Julie..that’s where we’re headed. Always asking questions before the doctor does anything to ensure we know how it will be billed. Thanks for sharing your experiences!
One would think physicians would know this too, wouldn’t you? But yeah, Julie..that’s where we’re headed. Always asking questions before the doctor does anything to ensure we know how it will be billed. Thanks for sharing your experiences!
Yes, it surprises me how clueless some physicians are about insurance. Having covered preventive care without additional charges is the cornerstone of health care reform (aka ACA aka Obamacare) so you’d think that they would understand they should code for an annual exam.
Yep, this just happened to me. $600 15 (not even) minute wellness exam. Makes me not want to tell the doctor anything