Pt. Doctor confidentiality vs. disclosure to insurance company

[paul1981]

What is the name of your state? California

My girlfriend and I went to a Planned Parenthood clinic to have a medical abortion procedure done. There were complications, and we went to a different hospital for follow up care with an OB/GYN, who decided that an emergency surgical abortion had to be done. We are now having issues with the insurance company paying for the procedure because the hospital coded the procedure as being done because of a failed attempt at a medical abortion (as opposed to a miscarriage/ectopic pregnancy, etc.). The insurance carrier is Blue Cross/Blue Sheild PPO. Is it not a breach of patient/doctor confidentiality for the hospital to disclose to the insurance company the reason for the surgical abortion? Is it not enough for the insurance carrier to just know that a surgical abortion had to be done, and leave it at that? What follow up action must we take, if there is any for us at all in this case?
Thank you for any help/guidance you can give us.
-Paul

[seniorjudge]

Originally Posted by paul1981

What is the name of your state? California

My girlfriend and I went to a Planned Parenthood clinic to have a medical abortion procedure done. There were complications, and we went to a different hospital for follow up care with an OB/GYN, who decided that an emergency surgical abortion had to be done. We are now having issues with the insurance company paying for the procedure because the hospital coded the procedure as being done because of a failed attempt at a medical abortion (as opposed to a miscarriage/ectopic pregnancy, etc.). The insurance carrier is Blue Cross/Blue Sheild PPO. Is it not a breach of patient/doctor confidentiality for the hospital to disclose to the insurance company the reason for the surgical abortion? Is it not enough for the insurance carrier to just know that a surgical abortion had to be done, and leave it at that? What follow up action must we take, if there is any for us at all in this case?
Thank you for any help/guidance you can give us.
-Paul

Q: Is it not a breach of patient/doctor confidentiality for the hospital to disclose to the insurance company the reason for the surgical abortion?

A: No.

[justalayman]

Did you not sign a form allowing the hospital to release the necessary info to the insurance company so they can make the appropriate decision concerning your wife's medical situation billing?
Did they code the procedure incorrectly?

[paul1981]

Originally Posted by justalayman

Did you not sign a form allowing the hospital to release the necessary info to the insurance company so they can make the appropriate decision concerning your wife's medical situation billing?
Did they code the procedure incorrectly?

Of course we signed the consent forms, they wouldn't have done the procedure otherwise. The hospital could have coded it as simply an emergency procedure, and not coded it as being secondary to a failed medical abortion. The hospital says that they won't change the coding, and therefore the insurance company won't pay.

It's looking like we're just **** out of luck, unless anyone knows if we can get the hospital to change their coding decision. It just seems like coding it as they did is releasing more information to the insurance company than is needed.

Originally Posted by paul1981

Of course we signed the consent forms, they wouldn't have done the procedure otherwise. The hospital could have coded it as simply an emergency procedure, and not coded it as being secondary to a failed medical abortion. The hospital says that they won't change the coding, and therefore the insurance company won't pay.

It's looking like we're just **** out of luck, unless anyone knows if we can get the hospital to change their coding decision. It just seems like coding it as they did is releasing more information to the insurance company than is needed.

Your out of luck. The hospital coded the procedure correctly. There are various ways to preform a surgical abortion and must be coded accordingly. THE HOSPITAL WILL NOT LIE FOR YOU!!! This is YOUR PROBLEM.

[URL="http://icd9cm.chrisendres.com/index.php?srchtype=procs&srchtext=surgical+abortion&Submit=Search&action=search"]http://icd9cm.chrisendres.com/index.php?srchtype=procs&srchtext=surgical+abortion&Submit=Search&action=search[/URL]


Next time...continue the pregnancy, insurance will cover prenatal visits and delivery, then give the baby up for adoption.

[justalayman]

Originally Posted by shellandty

Next time...continue the pregnancy, insurance will cover prenatal visits and delivery, then give the baby up for adoption.

Careful there or your going to start one of those "moral" threads that never end.

(btw, I'm with you on this)

It's looking like we're just **** out of luck, unless anyone knows if we can get the hospital to change their coding decision. It just seems like coding it as they did is releasing more information to the insurance company than is needed.

Man, it's hard enough to get them to do it right all the time and now you want them to do it wrong on purpose? Good luck, but I don't think it's going to happen.

While it may have released more info than you believe was needed, you are conspiring to commit insurance fraud. I really don't think the hospital will side with you on this.

Careful there or your going to start one of those "moral" threads that never end.

(btw, I'm with you on this)

You're right!

However, from a financial standpoint (which is what the OP is concerned about)...this would be the cheaper route to take when/if it happens again.