Insurance Claiming Age vs Doctor's Wording

[convoy71]

What is the name of your state? PA

My wife and I started with a new doctor and clinic a month ago. We found them via my online insurance(work insurance) data base.

My wife and 4 yr old son have their first visit with new doctor, what is submitted to my work insurance as "routine visit" although my son is submitted as "wellness visit"

A statement sent in the mail by my work insurance made this claim:
"A routine visit is not covered under the age of 40".

Two major problems I find immediately illegal:
1. A patient does not have any right or power over a doctor how they submit their report to billing, which follows to insurance company.
2. IT IS AGE DESCRIMINATION OF ANY KIND TO SAY SOMETHING WON'T BE COVERED UNTIL, OF OR AFTER AGE.

I talk to insurance company twice. They said they would not cover the submited bill due to the doctor writing "routine visit" but would cover my son which was submited as "wellness".

The secoond time the insurance company now claims, they are a third party and it's the corporate that owns the company I work for were whom created the rules.

AGAIN, HOW CAN ANY COMPANY CREATE RULES USING AGE AND USING SPECIFIC WORDING. AGAIN, how can you claim not to cover due to word that doctor submits on paper when a patient has no right or power how they word it.

[cbg]

1. A patient does not have any right or power over a doctor how they submit their report to billing, which follows to insurance company.

True, you don't. But the doctor doesn't have to lie, either. If it's a routine visit, he can say so. You don't have an absolute right to have every visit covered regardless. If routine visits are excluded in certain instances, that's the end of the story. NOTHING in the law says the insurance has to pay for EVERYTHING.

2. IT IS AGE DESCRIMINATION OF ANY KIND TO SAY SOMETHING WON'T BE COVERED UNTIL, OF OR AFTER AGE.

That may be. But in the circumstances you are describing, it is NOT illegal. There is NOTHING in the law that prohibits an insurance carrier from limiting certain treatments to certain ages.

[lealea1005]

Your claim had to have a diagnosis code (ICD9) and a procedure code (CPT) in order to be considered for payment by your insurance company.

Obviously, your son was seen for his well child check up and it was a covered service. If your wife was also seen for a "check up" ("routine"), it is very possible that your insurance company just doesn't cover that service for people under 40. It's really not that unusual.

To answer one of your questions...No, a patient does not have the right to dictate how a Physician should code a claim. The Physician's diagnosis/procedure coding for an office service must be supported by the documentation in your medical record. To ask him/her to change it so your insurance will cover it is asking them to commit insurance fraud.

[moburkes]

The majority of discrimination in insurance is legal. The majority of discrimination in life is legal. There are specific types of insurance that are illegal. If your insurance company said that they would not cover your wife because of where she lived, it would be illegal.

[ecmst12]

No, I'd say the VAST majority of discrimination in all areas of life is NOT illegal. Discrimination is ONLY illegal for certain reasons (gender/race/religion/etc) and certain circumstances (employment, housing). Everything else is fair game.

[moburkes]

Originally Posted by ecmst12

No, I'd say the VAST majority of discrimination in all areas of life is NOT illegal. Discrimination is ONLY illegal for certain reasons (gender/race/religion/etc) and certain circumstances (employment, housing). Everything else is fair game.

I screwed up. I meant to say legal. Thanks for catching that. I'll fix it.