Medical billing question - who should pay up? Anyone in the medical billing profession?

I received a bill in the mail from Quest Diagnostics. On the bill it said that my insurance only covered part of a service. I called Q.D and they told me that the insurance is saying that the particular service performed was maxed out for the year (service was done in 2008).

I called the insurance and turns out that my dr performed a service that is done once a year twice that year in 2008. Here's the pisser I had the first routine service checkup done in Jan 2008 then I went to visit the doctor in Dec 2008 to confirm a preganancy and while I was there she decied to give me the routine yearly checkup. I didn't think anything of it and I know she was doing it so I didn't have to come back to her in another month. But it turns out that my insurance did not cover it 100% of it because it was done in the same year.

It's not a huge amount of $$ but $45 is a box of diapers to me and I feel like my doctor's office should pay me this amount. Am I right, am I wrong?

Message edited 6/15/2009 8:08:33 AM.

Re: Medical billing question - who should pay up? Anyone in the medical billing profession?

Would your dr change the date of your appt. to Jan 2009 and resubmit it? I dont even know if it's legal for him to do.

Re: Medical billing question - who should pay up? Anyone in the medical billing profession?

Unfortunately it is not the MDs responsibility to know your insurance policy. I'm certain that a MD wouldn't do the service if they knew you would get charged like that. You can always try to bring it up to the billing department, but I don't know if it will get you anywhere.

Re: Medical billing question - who should pay up? Anyone in the medical billing profession?

Re: Medical billing question - who should pay up? Anyone in the medical billing profession?

I don't think you will get a dr. office to pay that. It is impossible for them to know each individual insurance policy and what they cover.
For example, my old ins policy only covered 1 routine gyno exam a year and my new one covers 3 - I guess it can't hurt to try but I doubt they will pay it. Sorry!

Re: Medical billing question - who should pay up? Anyone in the medical billing profession?

Re: Medical billing question - who should pay up? Anyone in the medical billing profession?

I would file an appeal with the insurance company. It may take a while but you may be able to get it approved.

My doc happens to be pretty versed in most insurance plans but he is very instrumental in running his business. Most doctors aren't.

Good luck.

Re: Medical billing question - who should pay up? Anyone in the medical billing profession?

Looks like I will take the route of filing an appeal claim with the insurance company.

It's just that my appointment with my doctor was for one thing only and she took it upon herself to perform the other service. I truely belive she did it to save myself a trip since I was there already but I didn't ask for it and now I'm bothered that I have to pay out of my own pocket because of it.

I am going to mention it to my doctors billing secretary and see what she tells me.

Re: Medical billing question - who should pay up? Anyone in the medical billing profession?

Re: Medical billing question - who should pay up? Anyone in the medical billing profession?

ultimately you are responsible for the charge.

you can file an appeal, but more than likely they will not pay it, since you really don't have any grounds.

it's not your dr.s office responsibiity to know how often of each procedure you can have done in a year, it's yours.

appealing will buy you time, but in the end, I don't see them "allowing" any more for the service.

and any suggestion regarding changing the date on the submission would be FRAUD, on your part and on the doctors.

and I would never want to meet you under those circumstances. (I investigate and prosecute health care fraud.)

please use this as an example to be more cognizant of your policy's benefits.

Re: Medical billing question - who should pay up? Anyone in the medical billing profession?

This is TOTALLY your doctor's fault. It is THEIR responsibility to confirm these things! I mean ultimately you are responsible to pay for it, but then they would lose a patient. I mean $45 is not the end of the world, but still, it is the principle of how they do business in the office.

I used to work in a dental office and it was OUR responsibility to check these things and make sure what amount the patient would be responsible for BEFORE they sat in the chair. If we ever $crewed up, my doctor would eat the charges bc he did not want to lose his patient.

Message edited 6/15/2009 11:33:52 AM.

Re: Medical billing question - who should pay up? Anyone in the medical billing profession?

This happened to us last year, but with the dentist. BUT it was that DH had gone for his 6 month checkup and did it ONE day before he was allowed to by insurance. ONE day!!!!

We filed an appeal, and won, but that was mainly bc we had to get the work done for the military by a certain date, and the dentist was not open on a Sunday. The dentist's secretary had also misdated the form by TWO days. So they waived it for us.

Unfortunately, I think you are responsible for this one.

Re: Medical billing question - who should pay up? Anyone in the medical billing profession?

dental offices run differently and a billed differently than drs offices.

most regular insurances run off of a discounted fee schedule with a dentist, so the dental offices needs to know what fees are associated with each procedure for each insurance. (ie, with GHI the patients get charged $28 per regular filling, etc) most times you pay up front for the service at the dentists office.

it's not the same with a dr.s office.

besides, ultimately, it's the patients responsibility to know the plans.

if a DOCTOR...meaning the medical provider and NOT a staff member of the office...had to memorize and know the exacty coding and payout of each CPT code for each insurance (and each TYPE of insurance within the companies coverage options) for each patient they treated...they'd have no room in their brains for actual medical knowlege.

Re: Medical billing question - who should pay up? Anyone in the medical billing profession?

A good Dr's office will not let that happen to a patient. Small co-payments here and there are understandable, but a good Dr' office will either make sure that a procedure is covered, how many times per year, etc. If my Dr's office did not do that, I'd run elsewhere. How good an office is managed is VERY important...they want MORE patients and they want their patients be happy, not lose patients. Performing a procedure twice in the same year was negligent on their part. They should have checked into it first. I'm sure there are a lot of other insurances that have the same requirements.

Re: Medical billing question - who should pay up? Anyone in the medical billing profession?

Message edited 6/15/2009 12:45:38 PM.

Re: Medical billing question - who should pay up? Anyone in the medical billing profession?

I'd probably call the insurance company, but in the end, I might just suck it up and pay.

IMO, she saved you a second trip to the office. For me, the additional co-pay and additional time I would have had to take off from work equals at least $45, so I wouldn't get too riled up about it. I would, however, keep a record of when I get tests done for future reference to avoid this mistake in the future.

Re: Medical billing question - who should pay up? Anyone in the medical billing profession?

you'll end up paying it. I've had much more outrageous things happen (being told to buy emergency medical supplies (diagnosis day before leaving country for 2 weeks) from no less than 4 different stores recomended by the insurance company, with all of the stores not having the items when I got there ... I ended up paying $150 out of pocket at CVS and fighting for months for a partial reimbursement).

so, from my experience, I suspect there is an equal chance of voter fraud being 'discovered' by the Ayatollah and a recount started as your insurance company determining upon appeal that they should pony-up some extra $.

Save yourself the grief, and pay the $ now.

(I can't tell you how much I want gov't managed health insurance)

Message edited 6/15/2009 2:41:33 PM.