Trouble getting insurance claim paid for routine medical procedure

I'm confused, on what grounds are they refusing to pay? Did you get a precert for the routine?

It meets the CAS standards due to my being at high risk for it. I have a PPO which does not need a referral I can go wherever I want, however my Doctor did give me a referral to have it done.

My cousins ( a male who had this as well, but survived) his daughter at age 30 gets annual screenings. Paid by hers, I'm 45 and they give me flack?

The Insurance company is refusing to pay unless I already had symptoms of cancer (how freaking stupid that is) such as blood in the stool or diahreah.

THe Doctor office is submitting it as a screening based on CAS ( I think is correct acronym) requirements at my age due to my father dieing from colon cancer. WHich they refuse to pay, If the doctor dreams up symptoms (since I have none obviously) means they are telling the Doctor to file a false claim.

You can file a appeal, it all depends on the terms and conditoins of your policy. Many policies restrct certain payments and require certain age or certain health conditions to be meet first.

But yes it is very ( very) common for doctors offices to have to fill out paper work the way the insurance wants it, if they are going to pay.

The doctor will and can hold your personally responsible if the insurance does not pay. You may try to sue the insurance company but you will need to show within the policy itself that is item is covered for your situation.

OK That certainly does NOT make any sense. I'm in the same category as you, my mother died of colon cancer which makes me a high risk. Even though my wife is not in the same risk category, she has had 3 of them in the last 8 years, all paid by insurance. What fly by night outfit is your carrier? Have they never heard of preventative medicine? Would they rather pay the greater costs of treating colon cancer? A colonscopy is a standard tool for early detection.

I would start with your state insurance agency. See what they recommend. Otherwise, you will have to file suit against the insurance company.

The standards I meant to say were the ACS (American cancer society) screening standards for at risk patients for screening. I clearly qualify for starting screening at 45 just on the basis of my father, my cousins case isn't the same and from my mothers blood line.

The insurance company said they will pay IF its submitted as a diagnostic exam.....they refuse to pay as a routine exam. The Doctors office that did the exam refuses to claim as Diagnostic even though my family doctor (primary care physician) specifically requested it as a diagnostic exam and has sent them (the gastro/enterology specialist)a letter to that effect.

Let them try and collect, I don't have that money, and I'm paying over $400 a month for a PPO insurance plan through my wife's employer. My employers insurance doesn't have a proper dental plan and they are bundled.

If they want paid they will file the claim the correct way. If they are too lazy to do that then I can't be expected to pay out of pocket for what should be a covered exam. Their obligation is to properly file the claim with the insurance company. They have not done so as of yesterday, and that's been 3 weeks now.

I will be calling the state insurance agency where I live as well as the one where my wife's employer is based. I have about had it with these idiots. I already have my wife talk to them since at this point I can't talk with them any longer without yelling.


My father avoided doctors and did not find he had colon cancer till it had progressed fairly far, He did a year of Chemotherapy as well as surgical removal but it still came back, he died 18 months after being diagnosed. Yeah, I am seriously HOT under the collar about this. I have to die before they cover an exam that can save my life. They cover Birth control Pills and Viagra, but heaven forbid you have an exam to find cancer at an early stage when you have a high risk factor.


I'll bet they (the Insurance company) pay for Colonoscopies for other people that work there under the same exact plan, its NOT a little employer, they have over 10,000 employees. I'd like to see them explain that to a jury. I have a mid range plan not the base or cheapest one.

So no ideas who I should go after, the Dr who's trying to make me fork over about $5,000 for a procedure the insurance will pay if it was properly submitted, or the insurance company for not paying an improperly submitted claim.

I don't have an extra $5K laying around collecting dust. THat Dr might but I don't and won't pay something I shouldn't have to pay if they did what they are responsible for doing. Such as properly sumbitting the claim which as far as today they are refusing to do.

They are refusing to resubmit it as a diagnostic and insisting its a routine procedure the insurance won't pay, which is contrary to what I told them as well as my Primary care physician who reffered me to get this says as well.

Don't pay and let them sue you. Then go into court and explain why you shouldn't have to pay.

They will send it to a collection agency, they already said that. At that point It becomes a slander against my name and credit history because I have a spotless record, and will take any action I can to go after anyone that tries to tarnish it.

No way in hell will I pay for a debt that should not exist if not for a lazy office that refuses to properly resubmit the claim.

But I don't want to leave the insurance company off the hook either. I pay through the nose for that insurance and they better pay what they are supposed to pay.

They seem to think the ACS guidelines that are universally recognized to determine who should be tested and at what point in ones life to start.

If my cousin had these wastes of flesh as insurers he would be dead today. He had a colonoscopy at 40 years old... He was found to have cancer, it required surgery, and a year of chemo, but he survived it. Had he waited as long as these people seem to think I should have he would have been dead years ago like my father was. And he died of colon cancer that started and progressed quickly BETWEEN his colonoscopies. And they have the nerve to suggest I don't need to wait till I am 50.

Sorry, I'm venting but these people (both the insurance and the wastes of flesh at the doctors office) have me this bent out of shape.

I am just trying to determine what my options are before I start trying to find a lawyer I can hardly afford to pay about a bill I can't afford to pay and shouldn't have t0 because of gross incompetence at both places.

Let them turn it over to a collection agency. Do a pre-emptive strike by informing the credit bureaus that this debt is the result of a dispute not an inability to pay and therfore should not be listed.