One thing to look into. Many large companies, you stated there were 10,000 employees, self insure. The insurance carrier may only be used for administration or stop loss, only paying out of their own pocket once a certain dollar amount is reached. Many states only apply the rules and regulations you quoted to fully insured plans.
If it is self funded your employer largley determines what is and is not covered. You may appeal to them to have it paid.

I'm seeing a lawyer that is specialized in insurance law Wednesday. If they pay for ANY colonoscopies (and I know for a fact they do) they will be hung out to dry since I have a history of gastrointestinal issues on top of the family history issue, plus have a letter from my primary care physician that sent me out for one. I'm going to find out what all my legal recourses are then. I'm sure there are some I haven't even thought of. I'm ticked off enough to pursue every one of them just on the principle of it.

The insurance company is reviewing the claim now. I appealed their decision based on the fact the physician claimed it was purely routine, when it isn't. The insurance rejected it based on that. And have filed my physicians statement that it was improperly filed and documentation backing it.

But I am bringing suit against the facility who refused to resubmit the claim even after my doctor informed them via writing I wasn't sent there for a routine procedure. Possible breech of contract since they refused to correct what they submitted. Not to mention the threats and rudeness from that office. Yeah I'm thoroughly disgusted over this, on Protonix now due to the incessant heartburn I've had since this started, and that isn't completely stopping it.

I've been calling all the TV stations to see if they need a good consumer mistreatment story. Man I love the options we have today to shame a business that screws its clients, between the internet, TV and so many consumer rights places even if I don't win, they are going to look bad to anyone who researches facilities before they have a procedure done. There are also lots of sites that review doctors... and all I have to do is be honest. This is so screwed in reality up why would I want to tarnish the facts by exaggerating any of them.

Not to mention all the state licensing boards are looking into them (the medical facility) now.

It's not just about the money, its about what's right. I don't pay over $300 a month for a PPO insurance plan that refuses to pay for things this important to me living. My father died from this 2 weeks after he turned 65 after fighting it for a year and a half (and yeah, that's real hard to watch and does make me hypersensitive on the subject)... my cousin had this in his late 30's. Luckily they got it in time and after surgery and chemo he is still alive. His Daughter was getting screenings in her 20's as a result.

Hate to vent, but hopefully the next person who feels screwed over by a doctor that reads this knows they have legal options even if nobody died or was maimed.

I do frown upon anything illegal.

OK, update time. Insurance company has paid this in full, however nobody has bothered to tell me this, I found out by accident. Plus I found out the insurance company doesn't even have a Summary Material Modifications (SMM) since 2001 as is required under federal law. They knew I was going to a Lawyer and paid up real quick and actually before I saw the lawyer, but like I said, its been over two weeks and they were required to notify me in 2 weeks time. I'm still waiting for that official notification.

The Doctor, and the Anesthesiologist are happy and consider the issue closed, BUT the Facility that prompted all of this by turning it out to collection rather than work with the insurance has not been answering their phone or returning messages left requesting a callback. They were paid in full by the Insurance company and yet still have this out to a collection company and have not recalled this yet. In effect they are trying to double dip on this. Collection company has been informed of this and my lawyer is going to draft a letter demanding they recall the collection and consider that bill paid in full with no additional fees. Right now I'm looking into the possibility of suing them for legal fees incurred by me as a result of their actions. Need to find out if small claims court is a correct venue for this or not in the Commonwealth of Virginia.

Turns out when you appeal an insurance companies final decision they have to get an outside specialist to review the medical records. In my case with 1st and 2nd degree family members with that cancer no doctor could argue a colonoscopy is a routine procedure before 50. Family history dictates its medically necessary even without symptoms and to say otherwise would be medical malpractice. Therefore no doctor will say otherwise without risking a lawsuit. This quoted by my Lawyer a specialist in Insurance law.

I know I won't get paid for my aggravation over all of this. But will settle for these fools to pick up my legal fees which are chump change to them but an important token to me.

And an important lesson to those reading this thread. If you feel you are getting shafted by the Doctor or the insurance company. Don't take their word on it and don't let them stall you for months like they did me. I'm sure a lot of people have paid out of pocket after getting the song and dance I was given when it should have been paid.

Time for one more update. This insurance claim was paid in full three weeks ago to all three billing parties, the other two of which are happy. This Medical facility however has refused to recall this collection. As far as I know this might be considered extortion and if anything is an attempt to collect money for a debt that doesn't exist. While I will admit the collection company has only called me once and they haven't called since the fact remains its still there. The medical facility has been refusing to return calls or even answer them now for weeks. They are using their answering machine to screen calls. I'm ready to go to the State police and see if they can be charged with a crime. I'm willing to give this another week before I act on it however.

The insurance company paid the claim after being presented with a simple one paragraph letter from my Primary care physician that the Medical facility refused to send since it conflicted with the claims they were making. So all parties have been paid in full however the obnoxious ***** that is the administrator of that facility out of spite refuses to recall the collection and is in effect trying to collect twice on a debt using threats to ruin my credit if I don't pay up what has already been paid.

Maybe she have a flash of common sense before she is gets charged with a criminal act.

And being this is over $250 in value I believe it's a felony.


Man I hope none of you ever has to go through this crap when you have you colonoscopies. And yeah, as distasteful as it is you will all have one eventually.

OK, this is likely the end of the road on this. The Better business bureau is officially involved and taking this seriously as of last week. Man did the administrator of that facility lie through her teeth to the BBB. I presented copies of her letters to them discounting nearly every single thing she said last week via writing on a line per line basis. Also as per the Collection agency the debt was officially recalled as of this afternoon by that waste of human flesh..

Now unless I am able to take them to court to recover legal fees there isn't much more I can do. I honestly don't know if that falls within the scope of small claims court or not, and even if it is whether I can get anything for the 3 months of hell they put us through, or the fairly piddly legal fees incurred so far, only $450. Personally I'm not sure its even worth the trouble, even on principle. It certainly isn't worth a regular lawsuit.

VERY, VERY late follow-up... Turns out I forgot to update this and I was reminded of the thread by another member. I had fogotten about it.

Turns out the Doctors office DID finally resubmit the forms once they knew I was going to a lawyer.

I was out the consultation of the lawyer, because they were subbmitting the forms the same day I had the appointment, without informing me of their intentions of course. So... long story short. The Moron office manager finally submitted what had to be submitted, HOW it needed submitted. And the insurance paid it in full.


They did try to take it to collection AFTER it was already paid by the insurance company... Nice trick... to double dip... I already had proof of payment from the insurance, dated and time stamped on the deposit BEFORE the tdate it was turned over... which I gladly sent copies to the collection agency, who quickly dropped it and sent letters to the credit agencies that it was fraudulently filed... and I guess went after them for monies owed for a debt they bought that didn't exist. I have no idea what happened in that area.

And long story short. NONE of the Doctors at the medical practice I have used for over 15 years will refer any patients to that practice.. or to that medical fascility for anything.

Turns out my case wasn't the first... and wasn't the only. But it was one of the last from any referals from my doctors. THere were others that complained as well, just few as loudly as I did. And yes... all were around the same timeframe.

They have developed a very bad reputation in the medical community in my area. They were caught in lies to the BBB (which I was able to document and prove were lies) and now have a record against them.

The actual Doctor, was a good one, I'll be fair to him... but everyone around him was NOT who he needed around him. And shows what apathy, incompetence, and sheer laziness can breed.

Don't know what happened to that doctor... if he got rid of the deadwood that filled the office or not... and I don't much care at this point since hell will freeze over before he touches me or my wife again. Because I won't deal with his office staff ever again. I hope he woke up to what was going on and fired the bunch. You don't want people like that working at McDonalds much less a medical office.

You know the saying... fool me once, shame on you, fool me twice, shame on me.