subscriber claim question

[velivolus]

I suffer from back pain, and after talking to customer service at my insurance company (Blue Shield of CA), I found out that I could get deep tissue massage done so long as it was through a chiropractic office or physical therapy office or M.D. I was told that I would have to pay according to my plan (I pay %40 at office, Blue Shield pays the rest) and was limited to 12 visits. So with this information, I found a chiropractic office that offered deep tissue massage services who was listed as a preferred provider by Blue Shield and went in. After the massage I gave them my card and explained my plan. The receptionist told me they needed to collect the full payment there and I would have to submit a claim to my insurance myself who might reimburse me some of the amount. I was a bit confused by all this, since it contradicted what I had been told by Blue Shield. I tried to talk to the receptionist about this but found she wasn't really listening and clearly just wanted full payment. I wasn't quite sure what to do under these circumstances, so decided to pay the bill and contact my insurance afterwards. The rep at Blue Shield I spoke with told me to submit the claim myself with diagnosis and procedure numbers. My bill has a procedure number but no diagnosis number. CS told me to call and get a diagnosis number from the chiropractor office. I spoke again to the receptionist at the office I had gone to, who said she couldn't give me a diagnosis number because I had not seen the doctor.

So this is where I am at now. I have submitted my claim and a copy of the bill, and explained that the provider did not give a diagnosis code, but I am concerned that without a diagnosis code I will get no reimbursement and I am bothered that I was originally given inaccurate information by CS. The receptionist at the chiropractric office was so unhelpful that I will not return to that particular office again, but I am still uncertain how to ensure I get the reimbursement I was told I would receive.

If anyone could give me some feedback about what to do in this situation, or what to do if my claim is denied, I'd appreciate it.

[esker]

Massage therapists in Chiropractor's offices are usually independent contractors. They are not employees of the practice. That might be why you are having this problem. Obviously, by hindsight, you should have asked before beginning treatment and not after. I'm sorry, that's not very helpful.

Furthermore, a massage therapist cannot give a diagnosis code as they are forbidden to diagnose. The chiropractor would have to diagnose you then write a prescription for the massage. So, the receptionist is correct on that point and CS may be able to legitimately deny the claim.

I once got massage therapy for an auto accident claim, but was very careful to work everything out ahead of time, making sure the massage therapist would be responsible for filing and collecting on the claim. I had also first gotten a prescription from a chiropractor. Later when the case was reviewed by the insurance company's doctor, he accepted the treatment as legitimate. It's important to get all your ducks in a row, so to speak.

I suspect that failing to see the doctor first is the biggest part of your problem. I suspect too that the massage therapist is an independent contractor and not an employee of the chiropractor.

[velivolus]

Thanks for your informative reply, Esker. I know now to ask a lot more insurance-related questions of the provider before making such an appointment in the future.

Assuming my claim is denied for lack of a diagnosis code, is there a way to appeal, on the basis of having received inaccurate information? Since I inquired about coverage from Blue Shield in advance and was told that massage done through a chiropractic office was covered, and that the provider would submit the claim, and that my portion of the payment would be 40% at the time of my office visit, I can't see how it is fair that I am left paying the entire bill. Had I been correctly informed I could have avoided this situation.

I guess for now I just have to hope my claim reaches an understanding person in the claims department.

[SpineAZ]

Unfortunately all insurance companies will say that no information you receive over the phone is binding - it in no way guarantees any type of coverage. The person you spoke with provided you summary coverage information but would not have been expected to explain all of the details. In an appeal the insurance company will likely respond that you should have consulted your insurance plan document prior to receiving or seeking the treatment.

What is unfortunate is that the chiropractor's office should have spoken to you before the treatment and asked for your insurance card. Or, had you offered it before treatment they might have told you that you'd have to file your own claim as you were not seeing the doctor.

You certainly can appeal, but I wouldn't want you to get your hopes up that the insurance company would agree to coverage.