EOB says I'm covered 100%

[Vanessa54]

Virginia
My health insurance covers preventatives 100%. If you are diagnosed and treated on your first preventative, the the next, you will have to pay into your deductible. This was my first. The doctors office coded it wrong and I was sent a bill. After some phone calls from me and my HR manager, I thought the issue was settled. I received my EOB from my insurance stating they paid 100%, my entire bill. Four months later, I have received a bill from my doctor. My HR manager at work got on the phone to both doctors billing and insurance. I received another bill yesterday. So I called the doctors billing and they say they never received a payment from my insurance other than what was applied to my deductible. I am trying to get this settled before the end of the year as my employer has changed our health insurance. Am I going to have to pay this bill even tho I have the EOB saying insurance paid it and the insurance was suppose to cover this 100% anyhow?

 

[cbg]

Because of HIPAA laws, your HR Manager is limited in how much she can accomplish, even with your signed release for her to act on your behalf. What you need to be doing is getting your insurance carrier involved. There should be a customer service number on the back of you insurance ID card. Call them and ask to be transferred to someone in Provider Relations. Explain to them the situation and ask for their assistance. They should be able to work with you to solve this. When you call, have all the documentation, including the EOB and all records of your and your HR Manager's previous calls. If possible, have your HR Manager with you. You won't want to do this before Monday in any case; Customer Service might be open 24/7(or it may not) but Provider Relations will work normal business hours 9-5.

Good luck. Let me know how it goes.

 

[Vanessa54]

Thank you. My HR manager still has my EOB and will let me know what she's going to do Monday when I go back in. Apparently this is why we changed insurance because this has happened to other employees. Insurance not honoring their 100% preventative coverage. At least I have the EOB stating they paid if I'm taken to collections. I will take them to court.

 

[cbg]

The problem is not all with your insurance company however. If this was preventive care, the initial payment should not have been applied to your deductible in the first place. It's not just your insurance that does not charge for preventive care - that's part of the new Health Care Reform Act which prohibits copays, deductibles or coinsurances for preventive care.

So your doctor's billing office is also at fault. They are the ones who coded it wrong, and they are the ones who wrongly applying payment to the deductible. Once the correction was made to the code, the payment should have been removed from the deductible and applied to the preventive care bill.

 

[Vanessa54]

When I got the EOB the first time, it showed I had to pay what wasn't applied to my deductible. This is how I found out it was coded wrong. I called the doctors and insurance as well as my HR manager did. We thought it was straightened out when I received the EOB stating my bill was paid. Now I'm getting bills again, four months later. This is so frustrating.

 

[cbg]

I don't blame you in the least. But that's where Provider Relations can help you. They can not only straight out the doctor, they can also assist with their own claims adjusters.

I've worked in some form of Benefits, including as an HR manager AND as an administrator for a health insurance company for over 30 years. I really do think that Provider Relations (or whatever your carrier calls it) is your best bet to resolve this. Unless you want to pay a bill you don't owe.

 

[Vanessa54]

Tried calling the Provider Relations and they are closed on weekends. So I emailed them. So I will just deal with being in limbo for the rest of the weekend and hopefully Monday we will all be on the same page. Thank you so much for your assistance.

 

[cbg]

Didn't I tell you they'd be closed on weekends?

Good luck. Come back on Monday and tell me how it went. P.S. Don't wait for them to respond to your email - call them anyway.

 

[barry1817]

billing

Virginia
My health insurance covers preventatives 100%. If you are diagnosed and treated on your first preventative, the the next, you will have to pay into your deductible. This was my first. The doctors office coded it wrong and I was sent a bill. After some phone calls from me and my HR manager, I thought the issue was settled. I received my EOB from my insurance stating they paid 100%, my entire bill. Four months later, I have received a bill from my doctor. My HR manager at work got on the phone to both doctors billing and insurance. I received another bill yesterday. So I called the doctors billing and they say they never received a payment from my insurance other than what was applied to my deductible. I am trying to get this settled before the end of the year as my employer has changed our health insurance. Am I going to have to pay this bill even tho I have the EOB saying insurance paid it and the insurance was suppose to cover this 100% anyhow?

EOB estimate of billing. As defined this is an estimate of what is to be billed, costs and patient payment.

While there are problems, this is what happens when third parties are involved in health care. Doctors fill out insurance forms and accept payment. In reality the world would be much better if patients paid the bills directly and they were the ones being reimbursed.

Excuse me for rambling on this matter.

I hope it gets resolved.

 

[lealea1005]

EOB estimate of billing. As defined this is an estimate of what is to be billed, costs and patient payment.

Barry, In OP's case, EOB= Explanation of Benefits

In reality the world would be much better if patients paid the bills directly and they were the ones being reimbursed.

I agree with you there.

I hope it gets resolved.

Me too.

 

[lealea1005]

Virginia
My health insurance covers preventatives 100%. If you are diagnosed and treated on your first preventative, the the next, you will have to pay into your deductible. This was my first. The doctors office coded it wrong and I was sent a bill. After some phone calls from me and my HR manager, I thought the issue was settled. I received my EOB from my insurance stating they paid 100%, my entire bill. Four months later, I have received a bill from my doctor. My HR manager at work got on the phone to both doctors billing and insurance. I received another bill yesterday. So I called the doctors billing and they say they never received a payment from my insurance other than what was applied to my deductible. I am trying to get this settled before the end of the year as my employer has changed our health insurance. Am I going to have to pay this bill even tho I have the EOB saying insurance paid it and the insurance was suppose to cover this 100% anyhow?

Just a couple thoughts.....

Preventative Care is provided to help prevent disease/illness/injury. It includes things like immunizations, PAP smears, prostate cancer screening, skin cancer screening, and basic screening bloodwork. It does not include ongoing treatment of already diagnosed conditions or the diagnostics invloved in treating said diseases. Morally and ethically, a Physician cannot ignore an already diagnosed disease/condition during a wellness or preventive "physical".

Coding for a preventative office service is very different than coding for an office service for a patient who had/has a medical history (high cholesterol, high blood pressure, diabetes, asthma, etc). If you presented for your initial visit to this Physician with ANY medical issues, most insurance company contracts require that it is billed/coded as a problem focused visit. Basically, that means all diangosis codes and service codes are changed to reflect the type of office service provided, therfore it would be coded correctly.

In the health insurance world, "covered" does not necesarily mean "paid". If your visit was applied to your deductible, it is considered "covered".

In know this info may be confusing, but I do hope it's helpful as well.

 

[Vanessa54]

Didn't I tell you they'd be closed on weekends?

Good luck. Come back on Monday and tell me how it went. P.S. Don't wait for them to respond to your email - call them anyway.

Sat in Hr today while on speaker phone with manager and insurance. They said to call the doctors office and find out why he put in his chart notes that this was a medical instead of a preventative. I called and the chart notes where checked and he had put that it was a preventative not medical. They don't know why it was submitted as medical, but will find out why and get back with me. The EOB was resubmitted because of the error stating insurance paid everything and I owed nothing. It was even stated on the EOB that it was resubmitted. The lady at the doctors office said there was nothing in my preventative procedure to indicate this was a medical issue.

 

[Vanessa54]

Just a couple thoughts.....

Preventative Care is provided to help prevent disease/illness/injury. It includes things like immunizations, PAP smears, prostate cancer screening, skin cancer screening, and basic screening bloodwork. It does not include ongoing treatment of already diagnosed conditions or the diagnostics invloved in treating said diseases. Morally and ethically, a Physician cannot ignore an already diagnosed disease/condition during a wellness or preventive "physical".

Coding for a preventative office service is very different than coding for an office service for a patient who had/has a medical history (high cholesterol, high blood pressure, diabetes, asthma, etc). If you presented for your initial visit to this Physician with ANY medical issues, most insurance company contracts require that it is billed/coded as a problem focused visit. Basically, that means all diangosis codes and service codes are changed to reflect the type of office service provided, therfore it would be coded correctly.

In the health insurance world, "covered" does not necesarily mean "paid". If your visit was applied to your deductible, it is considered "covered".

In know this info may be confusing, but I do hope it's helpful as well.

This was my first and last preventative. I'll never go thru this again. My insurance states that preventatives are covered 100%. I was diagnosed, but not treated. What I was diagnosed with, 80%+ are diagnosed with the same at my age. The lady at the office said it wasn't anything to justify me being billed as medical and it was noted in the doctors chart notes that this was a preventative, so they are looking into getting this error corrected.

 

[cbg]

Good. If you have any more problems, c'mon back.

 

[lealea1005]

This was my first and last preventative. I'll never go thru this again. My insurance states that preventatives are covered 100%. I was diagnosed, but not treated. What I was diagnosed with, 80%+ are diagnosed with the same at my age. The lady at the office said it wasn't anything to justify me being billed as medical and it was noted in the doctors chart notes that this was a preventative, so they are looking into getting this error corrected.

I understand what you are saying....but in the eyes of the insurance company, you have a diagnosis (percentages do not matter). It becomes a "problem focused" service because the ICD9 (diagnosis code) is required.

I truly hope you get this resolved as the system is just as frustrating for the providers as it is for you. Good luck.