Learning the Healthcare Claim Game

By Karen

What you don’t know about claims coding could cost you.

I had a long-delayed bone scan a few weeks ago, which was $220 on the spot if my insurance didn’t cover it. So I called my insurer, Anthem, to see if it was covered.

Anthem told me that routine bone scans aren’t subject to my deductible and are covered at 80 percent. I’d be responsible for the $40 co-pay plus 20 percent.

This week, Anthem’s “Explanation of Benefits” denied the claim, but knocked $80 off the original price, leaving me on the hook for $140. I’d have paid this if I hadn’t talked to Anthem before the scan, just assuming that everyone involved knew their job and had done it right.

Instead, I decided to find out what gives.

Anthem told me the doctor’s office coded the claim as a “diagnostic” scan for a “disorder of bone and cartilage unspecified.” That isn’t covered, but goes toward my deductible. However, “routine” scans are covered, as I was originally told.

I next phoned the doctor’s office. They said, “Unless you tell us to submit it as routine, we always make these claims diagnostic because that’s what most insurance companies will pay for.”

So now I’m supposed to know how to code claim forms and coach the doctor.

But they did readily agree to recode the claim and resubmit, which should save me $128 after I pay 20 percent.

The lessons here are 1) that you should question every charge because you could be paying big bucks for nothing, and 2) that most physicians will cooperate when it comes to getting insurers to pay up because there’s no love lost there.

And after the wringer Anthem Underwriting just put me through, the last thing I want in my file is an “unspecified bone or cartilage disorder” when my policy renews.

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