re: Doctor's Office Scheduled Exam Only If Health Insurance Would Cover It; Wasn't Covered

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Mrs. Golfer speaks/emails with insurance reps regularly when there's a coding/billing issue from her patients. And shes getting right to them, or they're at least calling her back within the hour to not disrupt her schedule.

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I got ya. A physician liaison to follow up with on issues. Understood.

But we can't call her for everyday benefits information. It would be 40-60 inquiries per day. We have to get to "eligibility and benefits" through the phone system and wait for a rep to answer.

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Aren't most of these available online via their system?

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Not very specific procedures. In my practice for example, nuclear uptake and imaging and biopsies/FNA's always require a phone call for patient benefit information. But an ultrasound, which we do on 40% of patients, is something we can use the online portal for.

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and each of our physicians is able to pull an "out of pocket" cost based on their codes right away...no need to send it off to them for an estimate.

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That's true, but is the procedure covered under your co-pay or subject to your deductible? Is the procedure a covered service under this self-funded (ERISA) Aetna plan, or this UHC HMO, or this platinum BCBS plan?

I need this to accurately calculate your out of pocket costs when you check out. If I biopsy your Thyroid, depending on your plan, you may have to pay only your co-pay, or you may have to pay the contracted rate b/c the procedure is subject to your deductible. That's what the reps on the phone tell me. And then the staff uses this info, and the appropriate fee schedule, to calculate your cost.

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Aren't most of these available online via their system? We have UHC with a high-deductible plan, and each of our physicians is able to pull an "out of pocket" cost based on their codes right away...no need to send it off to them for an estimate.

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Can your wife, A PT, tell a patient exactly how much each procedure will cost them? If she can she is one of the few, way too many insurance companies, way too many plans, way too many variables, way too many rules (one carrier has a capped daily rate, the next is on a fee schedule, next is on % of Medicare, one applies to deductible, next is copay only, next is 80/20 on some obscure fee schedule, etc and they all change frequently


all to say this is a very confusing area for all that are involved, as a patient,...know your plan, and a provider should not tell their patient how much something is unless they are 100% confident and willing to back it up with an adjustment

and as said earlier what does the EOB say, this is the most important part of the puzzle

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The specialist, after making the appointment, would have had to give us the exact names and descriptions involved in the screening.

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Right here, the specialists should have verified your coverage/eligibility. Not you. Whoever is providing the service should be able to calculate your costs.

What was the reason for denial? Your EOB should have a rejection code and notes for any denial of service. Depending on what it says, I can tell you the best direction to try and get it reduced if the option is available.