Back in February of 2005 we took Davin to the pediatrician for his 1 year check up. They weighed him, measured, gave him some shots, etc. We also asked the doc about a bad skin rash that Davin had. That simple question about the rash caused all kinds of confusion with our insurance company.
For reasons I won’t get into here, I’m philosophically opposed to health insurance, particularly the way it is implemented in America today. As a result of this opposition I signed up for the cheapest, most basic insurance that my company offers. We do not have a copay but rather pay a percentage of the bill, or the entire bill, depending on the type of medical service rendered. I also have a tax deductible MSA (medical savings account) which I use to pay these bills. As a result of this unusual insurance plan, it always takes the doctor’s office a month or more to get the bill straightened out. In addition, I need a fully itemized bill, receipt, and EOB (explanation of benefits) from the insurance company to get reimbursed from my MSA. To make a long story short, we held off on paying the bill from February (because all of this stuff wasn’t in order), and the doctor’s office ended up sending us a threatening letter. We paid the bill and then I started gathering the necessary info to submit my MSA claim.
I noticed something was wrong while looking at the EOB online. There were 2 separate claims, with 6 line items on the first claim, and 2 line items on the 2nd claim. The 6 line items on the first claim, which included 4 immunization line items, were all denied payment by the insurance company, meaning we had to pay 100% of the cost of those procedures. The insurance company paid the proper percentage of both items on the 2nd claim, however. I quickly realized that this was probably a $300 mistake and I started making some phone calls.
I called the insurance company and they explained that the doctor’s office had submitted the claim incorrectly because they had made the primary item a “medical diagnosis” which means that all of the remaining items fell under that same category which is not covered by the insurance company. That medical diagnosis was the doctor looking at Davin’s rash. I called the pediatrician’s billing office and they assured me that it was submitted properly. They said that the immunizations and routine checkup were coded as “routine wellness”, and that only the one item was coded as “medical diagnosis”. I called the insurance company again and they continued to blame the pediatrician’s office. Finally I got the billing office and the insurance company together on a conference call to hash it out. The two ladies went at it for a few minutes. I butted in with a “I don’t care whose fault it is, I just want to know how to fix it.” Eventually the pediatrician’s office got the call escalated to the customer service supervisor. We waited on hold for about 15 minutes and the supervisor finally came on the line and after a brief explanation she conceded that the insurance company had made a mistake.
They had indeed used the code from the first line item for the entire claim, which was incorrect. I still didn’t understand why the 2nd claim had gone through properly. The reason was simple. Their software only allows 6 items per claim. Therefore the extra 2 claims had to be submitted separately and were coded properly because the first item on the 2nd claim was an immunization. So, the mystery was solved and after 90 minutes and multiple phone calls we’ll be getting about a $240 refund. Victory is sweet! The moral of the story is to check your bills and your claims carefully to make sure everything is correct, and remember that when two companies are blaming each other, the conference call is your friend.