Tips on getting this medical bill paid?

[ajk912]

So I thought I had all my bases covered but I guess not. I took my daughter to the opthalmologist and normally I have a $30 specialist copay. The insurance company denied this claim, because we do not have vision coverage. We do, but it does not cover the opthalmologist, so I was hoping to do the visit under medical. I called beforehand, and did not get a name because I was not expecting a problem, and asked, is Dr. X covered? Yup, Dr. X is covered. I doubled checked on the website to make sure that Dr. X was an in network covered provider before going. Sure was. Now, I am getting the bill, and I have to say I am a little perturbed.

I called up and explained that my son has strabismus/ambylopia and had to have surgery for lazy eye, which is heriditar., I wanted to get that checked on my daughter, considering we caught it late with my son and he ended up losing vision permanently in that eye. The insurance company does not require referrals, you can see whoever you want. I even double checked their own website and the pediatric opthalmologist is covered. The rep told me she would send my story to appeals..I should get a letter in the mail in 7-10 days. That doesn't sound good at all, when something wasn't covered that should have been before, they were able to fix it that day.

Has anyone ever had this happen before? I have to say, this is crazy. Good thing my daughter has a clean bill of health, because it would have been really expensive if she needed the eye surgery like my son did, considering it's not considered medical according to the insurance plan. Ugh. Thoughts? Anyone BTDT?

 

[DizBelle]

Did you make it clear that your daughter was seeing the opthalmologist for a medical reason and not for a vision check up? I would think that would make it fall under medical coverage rather than vision coverage.

Did she also happen to have a vision checkup while there? That may be confusing the issue.

 

[KandD]

As PP said, the ophthalmologist's office should code it as a medical exam, not routine vision. They should be able to give a diagnosis code for the insurance company. If the billing department of the office won't help then ask to speak to the doctor because it should be under medical and not vision.

 

[lovemygoofy]

I'm not sure how your insurance company works but did you need a referral from your medical doctor for the opthamologist so the insurance can pay for it?

 

[bgirldeb]

can the opthalmologist submit a corrected claim?

 

[ajk912]

I'm not sure how your insurance company works but did you need a referral from your medical doctor for the opthamologist so the insurance can pay for it?

No referrals necessary with my insurance. I can see whoever I want. Sometimes the doc is out of network, so I just check the website and and find someone in network and schedule there. That logic has always worked for me..the website has never steered me wrong..except for this time. And I even called beforehandtoo, too!! Ugh.

She did end up getting a regular eye exam, too, and a prescription for glasses this go round. That's probably what's messing it up. And I did call to schedule a checkup (she had been last year too, different insurance, so she's already an established patient). Never had a problem with this before, and this insurance is usually great.

I am thinking I will see what happens with the appeal, and then call the doctor's office to see what they suggest. Thanks. My DH is telling me just to pay the bill, he doesn't want to alienate the pediatric ophthalmologist since there is only one in town. He doesn't want us to be a PITA on their side..but still, I hate just paying medical bills that should be covered, IMO, especially when I pay $600 a month for medical insurance and $15 a month for a worthless vision policy (only optometrists on this plan, none of them pediatric, either way, I wouldn't mind the out of network costs, at least that's 60/40 I imagine, better than 0% coverage). Ugh!!!

 

[mikehn]

The Drs office should be able to resubmit the correct code, if applicable. However, based on your original post, sounds like the visit was an elective vision exam and wouldnt be covered. Whether the opthamologist is in network or not, isnt really the issue.

Now lets say, your daughter was playing outside and a tree branch caught her in the eye and cut her eye. She went to the same opthamologist for an exam/surgery. That would probably be covered under your medical.

 

[ajk912]

The Drs office should be able to resubmit the correct code, if applicable. However, based on your original post, sounds like the visit was an elective vision exam and wouldnt be covered. Whether the opthamologist is in network or not, isnt really the issue.

Now lets say, your daughter was playing outside and a tree branch caught her in the eye and cut her eye. She went to the same opthamologist for an exam/surgery. That would probably be covered under your medical.

Actually, that's my entire issue. He's in-network, he should be covered. And what makes it further complicated is the pediatric opthlolmologist wants to see her back in 4 months, to see why her vision has gotten so bad so fast. And I do want to follow his advice, especially because of the mommy guilt of my son's lazy eye not being treated early enough. She's also a dwarf, to further complicate matters. So it just sucks that the insurance company won't pay the bill. Well, hopefully they will pay, I haven't received the results of the appeal yet. Takes about 10 days, from what the rep said.

 

[LuvOrlando]

I think this may be able to be solved in a faster way if the Dr's office is co-operative. Eye Dr's are only covered for injury to the eye, but not for general health what is your vision type stuff. So even if the Dr is in Network it doesn't mean the type of service is covered. Since nothing came up on the radar, as in her eyes were normal, the people who file the claims probably just listed it as a regular visit, which is why it was kicked back. See if you can get them to understand your point and re-code the visit as a visit for a hereditary disorder. If they do this and it's refiled, the appeal is un-necessary.

We have the same situation. I went to the eye Dr for a vision distortion but my eyes turned out to be completely normal. The disturbance was attributed to migraine and the visit was paid for. The one caveat is that if vision is tested for 20/20 during the visit the whole thing may not get covered. I had to go back a second time for my vision and a 3rd for contacts Not all Dr's offices are clear about these rules.

 

[My2Cinderellas]

I agree it was probably a coding error in the ophthamalogist's office when they submitted the claim.

I go through this all the time, I have a medical condition that requires yearly eye exams beyond the vision check, so my appointments are covered by insurance, even though we pay OOP for the rest of the family's vision checks. If the office submits my exam as a routine vision check the claim is denied. When they refile as related to a medical condition, they are covered.

Call the billing person at the dr's office and see if he/she can straighten this out.

 

[N.Bailey]

I know nothing about your situation, but did want to tell you what happened to us years ago. Hubby was in his early 20s and went to the ER. He was diagnosed with hypertension (runs in his family, but he was really young to be diagnosed with it). I don't think the fact that he was diagnosed was relayed to the insurance company, only that he was there due to hypertension and the insurance company didn't consider that to be an emergency.

So, I wrote them a letter explaining the situation. I said it was late in the evening, and was a weekend. I explained that we tried phoning the doctor's office, but there was obviously no one in. I then explained that my husband was diagnosed that night and that the doctor on duty said he would have probably died if he didn't get the medical care that he did.

They immediately covered the visit after reading the letter. I think you should give it some time to see how it plays out. It's likely they didn't have all the information and you probably cleared that up a bit for them.

 

[ajk912]

I think this may be able to be solved in a faster way if the Dr's office is co-operative. Eye Dr's are only covered for injury to the eye, but not for general health what is your vision type stuff. So even if the Dr is in Network it doesn't mean the type of service is covered. Since nothing came up on the radar, as in her eyes were normal, the people who file the claims probably just listed it as a regular visit, which is why it was kicked back. See if you can get them to understand your point and re-code the visit as a visit for a hereditary disorder. If they do this and it's refiled, the appeal is un-necessary.

We have the same situation. I went to the eye Dr for a vision distortion but my eyes turned out to be completely normal. The disturbance was attributed to migraine and the visit was paid for. The one caveat is that if vision is tested for 20/20 during the visit the whole thing may not get covered. I had to go back a second time for my vision and a 3rd for contacts Not all Dr's offices are clear about these rules.

Yup, this is pretty much what happened. I just called. They said that my son is covered because he has a diagnosed medical condition, but my daughter is not because her diagnosis is only astigmatism. They said if Dr. X would have noticed what my son has, it would have been covered.

So I will keep my fingers crossed with the appeal, but I am not going to get my hopes up. That's unfortunate, because she is supposed to do a followup with this doc in January.

 

[linda0706]

ajk912,

That sucks that they'd pay if the doc found anything but won't pay to rule out anything.

Here's my case...my dd wears glasses because of a medical condition. Her yearly ophthalmologist checkups ARE covered by our medical insurance, but the insurance company does not pay the eye test portion of the bill--I think that's called the refraction. So we have to pay our $50 specialist copay PLUS the $30+/- refraction charge.

Then we make our way to the optical shop & drop another couple hundred on glasses. Whew, it's an expensive day for us.

 

[daughtersrus]

I take my DD to a Pediatric Neuro-Ophthlamolgist yearly. She has a rare genetic disease and had cataract surgery when she was 2yo.

When we go, our health insurance pays for the exam part of the bill and the refraction (the exam for the contact/glasses) is covered under our vision plan.

We have all kinds of problems with our insurance (they're self-insured through DH's union) but this is one of the only bills that we don't have any problems with.

I would check with the billing office at the doctor and be sure that they used the proper code for medical first.

We have an appeal pending right now with the board of directors at the union office. Now, every time we take DD to see the ocularist (they make prosthetic eye pieces) we have to file an appeal because there are only a handful of people that do this in the entire state of IL and none of them are part of the BC/BS PPO. Our insurance is paying at a lower rate because they say that we "chose" to go out of network. I ask them for someone in network and they say that they don't have anyone but that it's still my choice to go out of the network. In the past they've ruled in our favor but say that it's a one time decision and we have to appeal every time.