Am I going to be responsible for this medical bill EDIT- taken care of

[ThisIsTheYear]

First I want to say that I'm very grateful that we have medical insurance!!!

On January 2nd I brought my son (5) to an Ear, Nose and Throat doctor because he's ALWAYS sick and has a sleep apnea. He tells us that he recommends for his tonsils and adenoids be taken out and for tubes to be put in. He did not do a hearing test but put a wand in his ear and they were able to tell he had fluid in there and needed to go on antibiotics. Then this Doctor told us he does not do the actual surgeries.

So we go to another ENT on January 9th (and I verified before hand that he does the surgeries). He put the scope in my son’s nose and asks us a ton of questions (the entire appointment was 2.5 hours). He verified that he needs to have his enlarged adenoids taken out and his tonsils. Then we went downstairs for the hearing test. First she put the wand in his ear. When I asked the audiologist what it was out of curiosity, she mentioned that it was to measure 'waves' or something similar to that and it's the same test they use to test the hearing on newborns at the hospital. Then DS went into the booth for the hearing test. His hearing came back perfect (and I'm guessing they verified there was no fluid) so he only needed to have his adenoids and tonsils removed, and this was done on Tuesday, Jan. 17th.

We received a bill yesterday from the insurance company denying the test they did with that wand. They said it was medically unnecessary and the test is only for newborns-3 year olds or adults who are unable to cooperate with other methods of hearing tests (individuals with autism, stroke patients). If I would have known this, I would have denied having it done. But I thought it was to determine if there was fluid in his ears (I still don't know if this is true).

I am definitely going to appeal but I was wondering what my first step should be? Should I call the ENT's billing department? Are they going to tell me to take a hike? I don't want to call my insurance company and say the wrong thing. Between the 2 copays from the 2 doctors, surgery and medication ($500+) , we can not afford to pay this bill - whatever it is.

Also, is there anything I can do about the copay for the first ENT? When I made the appointment I told them his pediatrician recommended an adenoidectomy and tonsillectomy. Before we shelled out $40, shouldn't they have told me, that the ENT doesn't do them?!

Thank you!


Edit- I called the ENT office and they said they are aware that it wasn't paid and they are going to recode it and send it in. Thanks for your help!

 

[Firefly09]

I would call the ENT office and discuss with them that the insurance is denying the claim. Claims are often denied because the office did not put in enough justifications as to why the test was necessary. The office can re-submit the claim with more reasoning as to why they needed the test. If the insurance company still rejects the claim, the office will usually work with you either by reducing the amount or working out a payment plan. You could try calling the insurance company yourself and let them know that because of this test, a surgery was avoided thus reducing further costs to them, but good luck getting anyone at an insurance company that can reason that far out.

Was the first ENT someone that your pediatrician recommended? One way to have avoided this issue would have been to go to someone recommended by your pediatrician if the first ENT was not, since they should know who performs surgery. When you called to make your appointment, there was no way for that office to know for sure whether or not your child actually needed surgery. They would need to see the patient first and make that determination themselves. So there is no point in telling you that the doctor doesn't perform the surgeries prior to your visit if they aren't sure if they are needed.

 

[Marionnette]

First I want to say that I'm very grateful that we have medical insurance!!!

On January 2nd I brought my son (5) to an Ear, Nose and Throat doctor because he's ALWAYS sick and has a sleep apnea. He tells us that he recommends for his tonsils and adenoids be taken out and for tubes to be put in. He did not do a hearing test but put a wand in his ear and they were able to tell he had fluid in there and needed to go on antibiotics. Then this Doctor told us he does not do the actual surgeries.

So we go to another ENT on January 9th (and I verified before hand that he does the surgeries). He put the scope in my son’s nose and asks us a ton of questions (the entire appointment was 2.5 hours). He verified that he needs to have his enlarged adenoids taken out and his tonsils. Then we went downstairs for the hearing test. First she put the wand in his ear. When I asked the audiologist what it was out of curiosity, she mentioned that it was to measure 'waves' or something similar to that and it's the same test they use to test the hearing on newborns at the hospital. Then DS went into the booth for the hearing test. His hearing came back perfect (and I'm guessing they verified there was no fluid) so he only needed to have his adenoids and tonsils removed, and this was done on Tuesday, Jan. 17th.

We received a bill yesterday from the insurance company denying the test they did with that wand. They said it was medically unnecessary and the test is only for newborns-3 year olds or adults who are unable to cooperate with other methods of hearing tests (individuals with autism, stroke patients). If I would have known this, I would have denied having it done. But I thought it was to determine if there was fluid in his ears (I still don't know if this is true).

I am definitely going to appeal but I was wondering what my first step should be? Should I call the ENT's billing department? Are they going to tell me to take a hike? I don't want to call my insurance company and say the wrong thing. Between the 2 copays from the 2 doctors, surgery and medication ($500+) , we can not afford to pay this bill - whatever it is.

Also, is there anything I can do about the copay for the first ENT? When I made the appointment I told them his pediatrician recommended an adenoidectomy and tonsillectomy. Before we shelled out $40, shouldn't they have told me, that the ENT doesn't do them?!

Thank you!

Surprise medical bills suck. I had to see a lot of doctors last year and there were quite a few tests and procedures done. One thing that I learned early in the process was to ask "Will my insurance cover this?"

Face it, the doctor's office has to deal with a multitude of insurance companies and each of them have multiple plans. Even if you have XYZ for your insurance, someone else who also has XYZ will have different coverage. For that reason, it is the PATIENT'S responsibility to know what is and is not covered. Or else ask before the procedure is done.

Your copay to the first ENT was your responsibility under your agreement with the insurance company and the doctor. He made the diagnosis and referred you to a surgeon that performs the procedure that you needed. The surgeon who will be doing the procedure is also entitled to his co-pays. I can't tell you how many times I've had to see my primary doctor first when I knew that the kids needed an orthopedic surgeon. The primary still got his co-pays just to say "Well, after x-rays, I see you have a fracture. You need to see the orthopedic group." Ummm, yeah. I already knew that. Two co-pays later, I would finally have a confirmed diagnosis and plan of treatment.

I suppose that you could have asked whether the first ENT performs surgeries prior to your visit. It's something that the medical community assumes that patients know to ask but people seldom do. Just file it away for future reference. There's bound to be a time when this comes up again.

 

[GoofItUp]

Find out from your ENT office why they did both tests. If they were both just for hearing, then there was no need to do both and they should not bill you for one of them. If there was another reason why both tests needed to be done, ask them to re-bill your insurance with some codes or explanation so the insurance company will be aware of it. Keep everything documented and be prepared to appeal with your insurance company if necessary. Advise the doctor's office what your doing (as these things take time and they'll need to know why they're not being paid.) If the appeals do not work, try to negotiate with your doctor's office for the additional charge.

BTW -- do pay the charges not related to the extra test.

 

[ThisIsTheYear]

He made the diagnosis and referred you to a surgeon that performs the procedure that you needed. The surgeon who will be doing the procedure is also entitled to his co-pays.

The first ENT was recommended by my pediatrician and I assume she didn't know he doesn't do the surgery. I don't need referrals with my plan either.
The first ENT actually wouldn't give us a recommendation to another ENT. Thank you for your help!

 

[disneyfreakk]

OP, what is the outcome? You edited your thread to say "taken care of". but you don't really give an explanation as to how it was handled.

 

[Firefly09]

It's at the end of the first post.

 

[disneyfreakk]

Duh, thank you Firefly09.