Why Was Covered Preventive Care Denied?
I am a male who is 51 years old and a father of three teenagers.
I went through a preventive Colonoscopy and Endoscopy after my gastro-enterologist discussed over the phone the procedure with the assigned doctor from Coventry, my insurance provider, prior to the procedure being performed.
Now, Coventry is denying the claim. They are not complying with the Affordable Care Act. The reason I went through the procedure because of their approval and because of the information on the Affordable Act. If they did not approve it, I would not have done it.
Do you have any resources that I can use to demonstrate to Coventry (or any insurance provider) that this is incorrect?
Preventive services are covered under the ACA, but there are a few important things to understand about how preventive services work.
- First, the preventive service needs to be billed and coded correctly. The doctor must code it as a preventive treatment / benefit.
- Secondly, in an HMO you may need approval (looks like you got that here).
- Thirdly, things related to the preventive visit or treatment may not be covered (like a drug you need to take before the visit)
- Fourthly, if you go in to get treatment for a preexisting condition it may not be counted as a preventive treatment.
- Lastly, you can always appeal, ask the insurer, and have the doctor recode. Often the denial will have a reasonable explanation or be able to be recoded. Also if your insurer approved the treatment they may cover it based on that alone.
If you can't find an acceptable resolution you can file both an internal and external appeal. Learn more bout appeals.
Learn more about preventive services and how they work.
Also, perhaps it's just a coincidence but almost every "letter" we get about denied preventive claims is related to gastro? Is something going on here we are missing. Feel free to chime in below if you are reading this.
I am 63 and also got a preventive Colonoscopy and Endoscopy. (15 years + since my last.) The doctor found and removed from my colon 2 small polyps which tested benign. Insurance paid @ 2/3 of the surgical center bill, and I paid 1/3, and I have no problem with that as I figured only the colonoscopy was a covered preventive. But we are still haggling over the doctor’s bill, and the insurer expects me to pay 100% of the anesthesiologist, and 100% of the biopsy. This because the 2 polyps were found and removed-to their way of thinking that makes it not preventive but diagnostic, and they changed the code the doctor sent in. To me, shifting costs based on findings is a DIS-incentive to preventive care. (Added costs for added work maybe, but not the whole thing!) So, what does the official concept of preventive include? Many thanks. (It is especially silly to shift the anesthesiologist cost. He would do exactly the same things no matter what the doctor was doing.)
This has been one of the areas of the law the has caused a lot of confusion. Preventive treatments are covered at no out-of-pocket cost, while other essential benefits are covered too (but typically with cost sharing). When a person goes in for a preventive treatment distinguishing between what aspects are preventive, what are essential benefits, and what are somehow uncovered out-of-network treatments is tricky. Is that medicine you need to take two weeks before surgery covered? Is that a diagnostic test and not a preventive test? Is this a doctors visit or a preventive visit? What is the difference anyway? Normally the best way to get things to swing in your favor is by appealing the insurance companies decision and hounding them to cover the tests as preventive. The stuff that is not covered at no out-of-pocket costs should at least be counted toward your deductible and out-of-pocket maximum. The best answers we have to all these questions and the best lists of what is covered we have found are all complied here: https://obamacarefacts.com/obamacare-preventive-care/
We are always looking for more insight and to have more people share their experience with preventive services. So anyone is welcome to comment more below.
what if a preventive services is done by an out of network provider should if still be covered at 100% can the patient be balanced bill?
No, not at all. You should always call your insurer before getting a service to make sure it is in-network (or if not if the out-of-network covers it or if they can make an exception, etc).