Has this happened to you? You go to the doctor to get some preventative care done and several days later you get the Explanation of Benefits from the insurer that shows you owe money for an exam you expected to be free. These bills may range from $50 for a very basic procedure to $1200 for a colonoscopy.
Many of the higher quality major medical and HSA qualified health insurance plans provide some outstanding free preventative care benefits. Even lesser health insurance plans are still required by Colorado law to provide a basic level of coverage for mammograms and PSA tests for adults and age appropriate child wellness exams and immunizations up to age 13, as per the American Academy of Pediatrics.
So what do you do when you get an Explanation of Benefits showing you owe money for that “free” preventative care? Let’s start at the root of the problem.
Sometimes clients unknowingly received care, such as additional testing, that their health plans don’t consider preventive. Many other times the problem comes down to the way the provider coded the claim. Doctors use a complex system of codes to identify each item or service provided on a claim form that the doctors’ office sends to the insurance company. The insurance companies’ claims department has computer systems that process the claims based upon how or if those particular codes are covered by the plans benefits.
More simply put, Garbage in – Garbage out. If the provider does not use a preventative care claim code, then the insurance company will process that claim accordingly and send an Explanation of Benefits showing how that claim was processed and the amount due.
A wrongly coded claim creates extra work for the provider, the client and the insurance company. You can try to first correct the claim with the insurer, by asking for a Senior Claims’ examiner to recheck the claim. Sometimes they can make an adjustment, but they are not allowed to add or remove codes, so don’t be surprised if they suggest you talk with the provider to correct the claim code. However, be sure to get as many details as possible from the claims examiner, so you can give the providers’ office clear guidance on how to correct this.
That being the case, the next step is for the client to call the provider’s office to ask them to correct the claim and resubmit that to the insurance company. The insurance company often may require documentation to prove that the resubmitted claim is accurate.
Some providers are very good about correcting these errors and others refuse to admit that an error was made and insist that the claim was filed correctly, which can result in a large bill for the client. However, when calling your providers office be very polite and do not be accusatory, as that will put them in a defensive posture which can make it all the more difficult to get your claim corrected.
Of course, the best method is to try and avoid this mess altogether and this is best done by calling your Agent to make sure you understand what is covered when. Make sure the provider you are seeing is in-network, and then communicate with the provider to help them to do their job correctly the first time.
If you think something should be covered as preventative care, then talk to the doctor and make sure the two of you are in agreement and, if appropriate, ask the doctor to be sure to use the correct preventative care code and to make a note of it in your file. That way, even if an error is made you will be on much better footing when you call to work with the office administrator to correct the bill.