I have a bit of a problem, due to family history (1 cousin had colon cancer and my father died from it), I was sent to have a colonoscopy at 45 by my primary care physician.

That was 3 weeks ago and the insurance company which is a PPO by the way not an HMO has refused payment, not just once but twice. I'm about to go visit that claim adjuster and perform my own colonscopy with my arm as I take that route to choke them.

I pay a pretty steep premium for the level of policy I have and I expect to have routine and required stuff like this paid.

The doctors office is refusing to file the claim in the manner the insurance company wants it to be filled out, what the insurance company wants to pay it technically amounts to fraud. I'll be damned if I am paying this out of my pocket since I pay these premiums of over $300 a month. I am insured and will not pay it out of pocket.

Who do I sue if this ends up in collection.

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 dying 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 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 it's a routine procedure the insurance won't pay, which is contrary to what I told them as well as my Primary care physician who referred 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.

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.
Great idea... I'll work on this the next couple days and get it off to the big three.

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.

Just a comment about medical costs. It is sometimes much more cost-efficient for the insurance company to pay for the expensive treatment instead of the inexpensive diagnostics. For example, if it costs $100/person to treat the disease, but only $1/person to vaccinate/diagnose it, you'd think that they would want to save the $99/person. But, if the incidence of the problem is low, so that they have to vaccinate 400 people for every one person that gets it, it actually costs the company more than if they just handled the sick people. (400/case prevented (if they vaccinate everyone), instead of the 100/case it would cost to treat it. Which means the insurance company is out 300.) Which is of no comfort at all to the one person who gets the disease that could have been prevented for a dollar. But insurance companies are out to make profits, and that is one of the ways that they do it.

According to ACS screening guidelines recognized universally in the medical community I should have had my first colonoscopy 5 years ago when I was 40. I'll bet some of the fool screwing around with me on this have had THEIR colonoscopies and I'll be willing to bet NONE of them were at high risk like I am.

I spoke with a friend of mine in the legal field, by agreement I can't repeat what he does. He did recommend $5 a month to keep it from collection, however do send copies of the claim to the big three and make sure its attached to you records and explain the dispute.

I'm waiting to hear from a few different law firms to see if I have a case to sue the insurance company for refusing to pay my claim because telling me I don't qualify for a claim is a deviation of the standards of care because my family history they are well aware of mandates its MORE important for me to be screened in my 40's than someone with NO risk being screened in their 50's.

I can forsee more ER visits rather than scheduled dr visits and more visits on any little thing I feel out of the ordinary. This is going to cost them in a big way down the road.

And up till now I really avoided going unless I felt really bad. That's going to stop.

Insurance company is arguing they don't pay more than $500 PER year total for what they claim is routine procedures. THat includes annual physicals, blood tests etc, total not per instance and this is supposed to be a PPO plan.

Little factoid I was told about, but have substantiated.

" All insurance companies in Virginia cover screening colonoscopy for EVERYONE in the state over the age of 50 - in fact, its a new state law."

That was notated from University of Virginia Health System (http://www.healthsystem.virginia.edu)

My father died from colon cancer, and additionally I had a second degree family member with colon cancer at 38, a cousin, surgery and chemo cured him, for the last 12 years anyway.

By the Bethesda protocol and ACS guidelines I should have had my first screening at 40 and this should have been my second.

Let them argue... I'm taking them to court. Let them explain this to a judge. AND add my legal fees to the bill as well since the Dr's office refuses to refile the claim as medically necessary with an explanation letter the insurance company said they would pay this in full. But the lazy $#@*&! At the Dr. office won't get off her butt and resubmit it.

And legaly I can't financially pay the bill in full as they demand... and the one place of the three that are demanding I pay rather than them ( the lazy SOB at the Dr's office) submit it in a correct manner has returned my partial payment... well they provided me proof that I made an attempt to pay in writing. Next month they get another check... if they refuse to accept that as well, I attempted to pay. They can't say I'm refusing to pay.


I'd love to mention the Dr's name to warn others to avoid that Gastroenterology practice until this person has been fired. So nobody else in my area gets screwed by them as well but I don't want to violate board rules. And I don't know if it will.

And I do know others have had similar problems even if they weren't in the a high risk group like I am.

Related question... I was told to send a partial payment pending resolution of this issue.

They wrote void across the check and returned it refusing it. I did make an attempt to pay... but they refused to accept it. Legally who is standing in the quicksand here. THey did put in writing they are refusing it. I don't have thousands of dollars on hand, they refuse to properly resubmit the claim in a manner that the insurance company wants it filed so they will be paid.

What money I do have will be going to legal fees it seems. Since this Dr.s office office seems to hire stupid people. I'd file against them in small claims court but don't want to ruin my chances in full court where I might get damages as well.

For those who reside in the Commonwealth of VA here is the state law copied verbatim. Don't let anyone deny you what you are entitled to.

§ 38.2-3418.7:1. Coverage for colorectal cancer screening.

A. Notwithstanding the provisions of § 38.2-3419, each insurer proposing to issue individual or group accident and sickness insurance policies providing hospital, medical and surgical or major medical coverage on an expense-incurred basis; each corporation providing individual or group accident and sickness subscription contracts; and each health maintenance organization providing a health care plan for health care services shall provide coverage for colorectal cancer screening under any such policy, contract or plan delivered, issued for delivery or renewed in this Commonwealth, on and after July 1, 2000.

B. Coverage for colorectal cancer screening, specifically screening with an annual fecal occult blood test, flexible sigmoidoscopy or colonoscopy, or in appropriate circumstances radiologic imaging, shall be provided in accordance with the most recently published recommendations established by the American College of Gastroenterology, in consultation with the American Cancer Society, for the ages, family histories, and frequencies referenced in such recommendations.

C. The coverage provided under this section shall not be more restrictive than or separate from coverage provided for any other illness, condition or disorder for purposes of determining deductibles, benefit year or lifetime durational limits, benefit year or lifetime dollar limits, lifetime episodes or treatment limits, copayment and coinsurance factors, and benefit year maximum for deductibles and copayments and coinsurance factors.

D. The provisions of this section shall not apply to (i) short-term travel, accident only, limited or specified disease policies, other than cancer policies, (ii) short-term nonrenewable policies of not more than six months duration, or (iii) policies or contracts designed for issuance to persons eligible for coverage under Title XVIII of the Social Security Act, known as Medicare, or any other similar coverage under state or federal governmental plans.

(2000, c. 888.)

Beyond that I will not comment upon the state of my problem until after resolution, at which time I will publish what the ruling is.

So yes they will pay and cover it as long as you are not over your amount for screenings. If they have a total max, then it would be shown by the insurnae company as covered test but if the max for those things are already paid, then they will not pay any additional

Well, I got the first threatening phone call from what claims to be a collection agency, (yes, time date who and topic was noted in a folder) I have an appointment with the lawyer ( He specializes in Insurance law) next week to bring suit. I've exhausted all administrative recourses so now legal action is open.

I've filed an appeal with the insurance company and have a letter from my physician stating I was referred there for a number of symptoms along with my family history... It should have been filed as medically necessary not routine... Might have a malpractice issue as well since the Dr. That did the procedure is arguing I was asymptomatic when I wasn't. Just because they found nothing. And that makes all the difference between how the insurance pays this. 2 months they refused to resubmit the claim even when submitted written proof they were wrong.

Well, Now I'm after blood, this is beyond a simple mistake, and even beyond incompetent office staff, they are actively trying to lie and defraud me of money.


Well, time to let a judge decide this now in court. I'm tired of talking till I'm blue in the face.

And yeah, I've already filed official complaints with all licensing agencies, and every consumer protection group I could contact as is my right. Nothing has been exaggerated, only the facts have been stated. I was careful so nothing can be considered libel or slander as its all documented.

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.