Screenings at different ages. And deductables. - Health Insurance Issues Message Board

Pootsi · 02-01-2004, 01:24 PM

Are insurances suppose to cover screenings when you reach a certain age? Like angiograms, ostipourosis, diabetes, mammogram, etc.
Also, I was charged a $500 deductable from my insurance plan (Guardian) because a routine colonoscopy I had done was done at a different building than the building my doctor worked in, but my the same doctor (in network). My insurance said it was also because it was a part of a treatment from seeing him earlier, which wasn't. My doctor told me it needed to be done because of family history.
Now my husband is going to be charged $500 deductable because he's going to have sinus surgery done outside of the doctor's clinic, in the hospital. He's an in network doctor also.
Is there anything I can do about all this?

rubindj · 02-08-2004, 01:16 PM

Quote:

Originally Posted by Pootsi

Are insurances suppose to cover screenings when you reach a certain age? Like angiograms, ostipourosis, diabetes, mammogram, etc.
Also, I was charged a $500 deductable from my insurance plan (Guardian) because a routine colonoscopy I had done was done at a different building than the building my doctor worked in, but my the same doctor (in network). My insurance said it was also because it was a part of a treatment from seeing him earlier, which wasn't. My doctor told me it needed to be done because of family history.
Now my husband is going to be charged $500 deductable because he's going to have sinus surgery done outside of the doctor's clinic, in the hospital. He's an in network doctor also.
Is there anything I can do about all this?

This depends entirely on your policy. If it is a policy through work, they often cover screenings, but a personal policy will usually only cover the state required minimums.

csoar2004 · 03-02-2004, 10:24 AM

Quote:

Originally Posted by Pootsi

Are insurances suppose to cover screenings when you reach a certain age? Like angiograms, ostipourosis, diabetes, mammogram, etc.

There is no law requiring it, no. However, whether a particular plan does or doesn't cover routine screenings depends entirely on the coverage paid for.

Quote:

Also, I was charged a $500 deductable from my insurance plan (Guardian) because a routine colonoscopy I had done was done at a different building than the building my doctor worked in, but my the same doctor (in network). My insurance said it was also because it was a part of a treatment from seeing him earlier, which wasn't. My doctor told me it needed to be done because of family history.

If colonoscopy is a covered service when done for a reason (your family history) other than routine screening then you may be able to get this ruling reversed. However I suspect that your doctor will need to submit a revised billing to the insurance company putting the reason (a diagnosis code) rather than indicating it was routine screening based on age (a different diagnosis code). This means you must start by requesting that the doctor resubmit the bill to your insurance.

Quote:

Now my husband is going to be charged $500 deductable because he's going to have sinus surgery done outside of the doctor's clinic, in the hospital. He's an in network doctor also. Is there anything I can do about all this?

You can always argue with your insurance company. Ask them under what circumstances such surgery is covered and then try to make that happen. It might mean that your doctor has to change the venue (the 'where') or it might mean that your doctor must refer your husband to an ENT (ear, nose, throat specialist) to perform the surgery.
It might take a lot of effort on your part, but ultimately, the squeaky wheel gets greased and most insurance companies count on the fact that most of us will give up after the second "no."
Don't give up.

katiesquilts · 04-10-2004, 10:09 PM

Quote:

Originally Posted by Pootsi

Are insurances suppose to cover screenings when you reach a certain age? Like angiograms, ostipourosis, diabetes, mammogram, etc.
Also, I was charged a $500 deductable from my insurance plan (Guardian) because a routine colonoscopy I had done was done at a different building than the building my doctor worked in, but my the same doctor (in network). My insurance said it was also because it was a part of a treatment from seeing him earlier, which wasn't. My doctor told me it needed to be done because of family history.
Now my husband is going to be charged $500 deductable because he's going to have sinus surgery done outside of the doctor's clinic, in the hospital. He's an in network doctor also.
Is there anything I can do about all this?

You will need to contact whoever at your employer helps with insurance issues. If the insurance co is telling you that the colonoscopy was part of a treatment, it's because of the way it was coded on the cpt form. You can ask the doctor to rebill to show it as wellness. Before you do this, though, what is your wellness cap? If your policy only covers up to a certain dollar amount for wellness, you may end up paying more than your deductible. Also, you may want to check it out further--some companies consider colonoscopies to be out-patient procedures, regardless of the outcome.

pull out your plan description. Your husband's procedure is probably okay, since it's out-patient surgery and, regardless of whether it's in or out of network, the deductible probably applies.

michelle