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Dr's incorrect coding kicks in waiver

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Jeanine Thames

Junior Member
What is the name of your state? Texas

Part of our benefits with our insurance co. (Unicare) include a routine colonoscopy after the age of 50, provided we have met our deductible. My husband got a ROUTINE colonoscopy and everything was prequalified. My husband has a waver for anything "gastro-intestinal" for the 1st 5 years of the policy, which was in effect at the time. The Dr. was promptly paid by Unicare, but the facility has never been paid, because he used extra codes referring to a diagnosis which set my husband`s waver into effect. Why should the Dr. receive payment and not the facility? He refuses to change the codes.
How can he justify using 2 different sets of codes for the same procedure?......especially when his coding for himself got him paid so promptly. As I understand it with my insurance, the ROUTINE colonoscopy is part of our benefit, regardless of the diagnosis.
I'm not sure who I should be going after**************any advise is appreciated!
 


ecmst12

Senior Member
If the doctor got paid with the same set of codes that the facility got denied with, I'd start by calling Unicare and asking why. If the codes on the doctor's bill are different then the ones on the facility bill, then one of them is clearly wrong; find out which it is.

Was it truely routine or does he have another condition that would require regular colonoscopies?
 

Jeanine Thames

Junior Member
incorrect coding

Exactly!.....The Dr. added 2 extra codes to the facility bill.....I agree that one of the codings must be wrong. Of course our insurance has already paid the Dr. and we would hate for that to be reversed**************and yes, it was ABSOLUTELY a ROUTINE colonoscopy.....that was our intention going into it, although my husband probably discussed details of hemmhorroid problems he had had in the past in his preliminary meeting...(these problems were years ago) But this was certainly not the reason for the colonoscopy**************my husband really wants to take care of his health.

If the Dr. refuses to discuss this with us (he won't return calls, and I can't make an appointment with him because we have now gone to another gastro Dr.) what should we do? Insurance is like a brick wall**************...Can I take the Dr. to small claims court, or file medical malpractice? (I think he has taken it personally that we have changed Drs.)

Thanks so much for your response.
 

ecmst12

Senior Member
Well, your easiest 2 options are to discuss the situation with the doc's office manager or billing manager, or to file an appeal with your insurance. Or both.

You definitely can't file medical malpractice since there was none. Malpractice means (among other things) that the patient's health was harmed, not that they are getting an erroneous bill.

I don't know if you can sue THEM; they are sending YOU a bill and if you or your insurance doesn't pay it, they can sue YOU. There's a thread right next to yours about someone this happened to, you should read it :)

But if the code they billed is truely incorrect and they refuse to change it, that is fraudulent. You might want to remind them of that. Also, if the doc is contracted with your insurance company, it's possible the provider representative from Unicare that works with them can intervene on your behalf.
 
You need to call the billing office of the FACILITY where the test was done.

There would have been 2 separate bills submitted by two entities. One-the doctor, Two-the facility. I imagine the colonoscopy was done at your local hospital or clinic, and the billing office there would be responsible for the coding.

Call them, explain it was a well-check colonoscopy, and ask if it was coded as such when the bill was submitted. If it was not, appeal with them. If it was coded as a "well" test, then appeal with Unicare since you state well tests should be covered. You can always ask for the office notes from the referring doctor showing it was a routine request, as well as the test results to support this.

If I knew the diagnosis codes used on both bills, I could be of more help--
 

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