Health Insurance question - doc's office put in wrong code

[moemac59 192]

Hey VJ peeps,

I know that this isn't an immigration question but I need some help as I am new to the whole US health insurance thing. I went to see the doctor back in January for an issue that I was having. This is the first and only time that I had been in to see this doctor. The issue that I was having is now gone. Well I just got a letter from Kaleida Health yesterday telling me that my claim is going to be denied due to a pre-existing condition??? How can this be since I have never even seen this doctor before and have never had this problem. When I went into that office, I was actually looked at by the nurse practioner and not the doctor. The doctor was not in.

When I called the insurance company about this, they stated that the doctor's office coded my information as pre-existing. Well this is news to me since this is the first time that I have had to deal with this health issue. I want to know what I have to do to fix this. I am going to call the doctor's office to ask them to correct their mistake but am curious as to what I can do if they won't.

Can insurance companies really deny you because of this? I thought with the the whole Obamacare that they were not able to do this anymore.

Any info or assistance on this would be greatly appreciated.

Moe

[Ontarkie 14,227]

~~Moved to Moving Here and Your New Life In America, from Off Topic~~

[serena28 2]

You're right, your health insurance cannot deny because even if the doc's office quoted the wrong code, the new health insurance (obamacare) beginning 2014 cannot deny for pre-existing conditions.

Based on personal experience, I got pregnant while I was searching to buy health insurance in Nov 2013. No one was giving me health insurance in 2013 but beg 2014, they couldnt deny me because I was pregnant (considered a pre-existing condition). This country is amazingly confusing when it comes to health insurance rules.

I would call your doc's and ask them to fix this because it would be easier to have them fix it rather than arguing with the insurance company.

[Kathryn41 3,205]

One of the things I discovered my first year here was just how often doctor's offices and insurance companies make 'mistakes' on coding for billing. Interestingly, it never seemed to be an error in 'our' favour, either.

You need to be your own advocate when it comes to health insurance in the US. Make sure you keep all of the Benefit Statements that you receive and be sure to match them up with any invoices or bills you receive from doctors, hospitals, labs, etc. because you will probably find similar problems re-occuring.

In this case, go in person to the doctor's office and take your letter of denial from your insurance company with you. Explain to them that you have health insurance but because the doctor's office put in the incorrect code, your claim has been denied. Ask them to make the necessary corrections and re-submit the claim with the correct code to your insurer. Tell them to be sure to put on it that it is a re-submitted 'corrected' claim - (I had a go around of 3 re-submissions and 3 refusals because the insurance company just saw the 'same' item re-submitted and didn't bother to check any further so didn't see that it was 'corrected'. I had the doctor send in the statement with 'corrected' on it and I notified the insurance company to expect the 'corrected' submission. That time it went through).

I doubt you will have a problem with the doctor's office. I have had to ask doctors' offices to correct errors and re-submit things so many times that I have literally lost count. My first year here, I actually felt they should be paying me because it seemed like I was doing the legwork to make sure they got paid from the insurance company. They are probably used to having to correct these sorts of errors.

Edited February 20, 2014 by Kathryn41

[kissmystars83 5]

Im a medical biller. You just need to contact the dr office and tell them you need a diagnosis code review. Tell them you need the dr to submit new coding due to this was not pre-existing. The dr will give new codes and will have ur claim go back to your insurance carrier. You need to make sure this happens. It would be wise to contact the insurance carrier after you spoke with the dr and once you receive notification of the change. If the insurance carrier still denies your claim with the new coding you can appeal. You will need to appeal with records.

[moemac59 192]

Im a medical biller. You just need to contact the dr office and tell them you need a diagnosis code review. Tell them you need the dr to submit new coding due to this was not pre-existing. The dr will give new codes and will have ur claim go back to your insurance carrier. You need to make sure this happens. It would be wise to contact the insurance carrier after you spoke with the dr and once you receive notification of the change. If the insurance carrier still denies your claim with the new coding you can appeal. You will need to appeal with records.

Thanks Kissmystars, I actually got it sorted out. The insurance company had put down the wrong date of service and it was corrected. The doc's office had the correct information.