[lemon]

I do appreciate if anyone can help. My case is as follows:

I did a physical examination on July 11, 2005, several weeks after I came to America, and on April 19, 2006 my doctor arranged me another physical examination without telling me it's necessary or not when I only requested immunization injections for my graudate admission.

My insurance rejected the claim on the physical examination provided on April 19, arguing that their policy - "one preventive physical examination every five calendar years from 22 through 29 years of age" and that I took two preventive physical examination in two years, which is not allowed.

The problem is that, I never received any detail brochure stating that policy and what I only have before I decided to enroll this plan is two-page benefit features which doesn't have so detail information.

So, what are my options?

Thank you so much!

[Cgirl]

I don't know who you have for insurance... but maybe if you gave your insurance company a letter from your doctor that ordered this second physical, that he/she thought it was a necessary procedure, maybe they would cover it? I know I have had many problems with my insurance in the past... and most of the time they hope that you will just pay it and not ask any questions of them, if I were you, I would do just the opposite, ask more questions and keep on them... only pay a small amount towards the bill every month to keep it out of collections, and see if there is any other options of them paying for it. The other option is sueing... but it is VERY hard to sue insurance companies... this could take years... and you probably won't win because they usually are a million dollar company... and in the mean time your credit goes to hell. Hang in there, I wish you the best!

[Fr_Chuck]

There are 1000's of insurance policies with various terms and conditions.

And they will only pay according to their terms of the policy regardless if you know or understand them.

It is normally your responsiblility to ask questions and know what your policy does or does not cover. Next if in doubt you can always call and ask prior to any procedure or visit.

And also regardless if your doctor asked you to come to or go to some other exam, it appears there may be a reason he wanted you to go for a second check up. So that should have also been your next question before going to another doctor visit , why do I need to doctor ?

So not asking questions and just hopeing something is covered is not being responsible for your own money.

You will owe the doctor and need to arrange to pay them.

[lemon]

Thank you both of you.

To Fr Chuck,

Before my visit to doctor, I consulted my insurance company if immunization service is covered or not, and they told me it's covered. In effect the insurance company paid out all the cost of every kind of immunizations I took. Inaddition to bill the immunizations procedures, the docotor's office also coding preventive physical examination to the insurance company which was rejected. The argued that immunization injection is preventive service and that this is the way they code. By the way, I confirmed with the nurse who did the injections to me that all the services were covered by insurance. Therefore, I did ask everything prior the services done. Do you think it's still my responsibility to pay for the balance?

Moreover, after I received the claim rejection and knew that I can't take twice physical information within five years, the insurance company sent me their policy brochure twice. I don't know if they want to remedy something because they never send me that.

Fr Chuck, any further suggestions?

[Fr_Chuck]

I would question the coding, often if you explain this problem to the doctors office ( not doctor) they can see if they can re=code the billing and resubmit.

And I was where you were at, I had to have a series of shots over 6 months, I was told that they were covered, but turned out they were but that they applied my 20 dollar dedcutable per day per shot, and guess what each shot was only 19 dollar, so getting a shot every day for about 3 months, I got the bill, This was about 3 years ago, and I just finally settled with them over that payment, since the insurance company never paid anything but "would have paid, if they were over the deductable, I was given an impression that it was going to be one bill paid at 80 percent, not billed daily.

Next no matter how much the doctor bill is, ask them to take some off, I have never had a doctor not take off at least 10 percent, but many take off as much as 1/2

[Cgirl]

Very true... good advice!

[lemon]

Mr. Fr Chuck,

Thanks for your advice. I tried again to ask the doctor's office to request if they can re-code the billing, but they insisted they are right and didn't agree to change the code.

If so, how can I ask the doctor to take off the balance?

[pumibel]

See if the doctor's office will talk directly to the insurance company to work this out for you. I have found that I don't get anything done by being a "go-between" . Since the Dr wants to be paid, they are probably most likely to do the calling. I really doubt the insurance will call the Dr.
I was seeing a doc whose office was constantly making errors with billing. Once I was turned away for care because they had made an error that caused me not to have authorization for the visit. The insurance arranged one more visit for me, and then gave me names of other doctors so I could see someone else next time. Perhaps your insurance can provide you a list of doctors with whom they hae a good history.

[Fr_Chuck]

And of course you can ask the doctor or any medical professional to write off part of the debt. I recently had to go to the ER over a medical issue.

I asked the hospital to write off part of their balance and they wrote off 50 percent, I asked the doctor to write off part of his, and he wrote off 25 percent or so, I asked the medical test people, and they wrote off 50 percent. The ER doctor billing service was the only one not to write off anything, ( and I am not done trying, I have paid 1/2 up to this point and going to wait 30 or 60 days and try to settle again.