Question
What is the name of your state? CA
I had a medical exam because DR. said I need this exam as a
"medically necessary" but my insurance company regards this exam is just a
"preventive care" and they denialed my claim...
Insurance company said if DR. doesn't change my "diagnosis code", they still regards this exam as a "preventive care". I asked DR. to reclaim but they denial my request. They said changing diagnosis code is an insurance fraud however, they said this exam is "medically necessary".
I knew that my insurance doesn't cover preventive care, so I asked DR. and made sure that this exam is a medically necessary and not a preventive care BEFORE I took this exam.
Is their any posibility that I can change their mind? I can't afford a $1600!! for this simple exam and since DR. said this exam is a "medically necessay", I think they have to responsible what they said to me...
It looks like DR. doesn't care because it was happened in the last year and they excused they doesn't have a responsibility for insurance company's decision. Then why they told me that this exam is "medically necessary"?
Should I find lawyer or go to the court?
Thanks
Answer
You need to file an appeal with the insurance company. Check their web site for more information (or your policy/contract)
Answer
What type of exam? Your doctor can't change your diagnosis code, treatment code is a different thing. If there was a question you should have asked to have the test pre approved, but all that should be explained in the plan description and the means by which to appeal.
Answer
Did you go to the doctor because there was something wrong with you? As in, were you sick or injured or something?
If the "preventive care" diagnosis code is WRONG(a mistake), they can change it without being fraudulent, but if it's correct obviously they can't.
But if this was NOT a preventive visit, then they shouldn't have a preventive code on there.
Answer
At this point and time, if your insurance company doesn't request your complete medical records for review, they're a bunch of idiots. Most insurance companies are not going to pay a $1600 bill because the doctor conveniently changes the CPT or ICD-9 codes from the first billing. They'll request the records, they'll review them, and if it's found out he fudged the billings, he'll have the fraud department looking at every claim he submits in for a long time.
You didn't self refer yourself to one of these "executive" or "comprehensive" health places, did you? These are places that offer an excessive battery of tests no matter what your actual medical history or current symptoms and charge ridiculous prices for. They also perform tests that are considered experimental/investigational like CT scans of the heart, etc. A lot of those try billing with medical DXs too and claiming their services are "medically necessary", but they charge so many CPT codes and charge such a ridiculous amount that they're easy to spot. It's an overinflated preventive exam.
Answer
Thank you for your suggestion.
Actually this is not an insurance company's fault yet, stupid DR.'s fault.
However they said this exam was a medically necessary, they deny to change diagnosis code... I had a typical symptoms of endometriosis and since I have a family history of this sickness, my former DR. told me I should better to see a DR. once any symptoms hits on me. Because this sickness is seriouslly affects on sterility in future.
Should I go to the court and complain about this stupid DR.?