WTF doc (and insurance tales)

[Kaylyn]

(I shouldn't have to say this by now, but healthcare reform debates go thataway *points to Fratching*. Limit discussion of Affordable Healthcare Act to the logistics of how it's meant to work, not on your opinions of it.)

My husband went to a new doctor a month or two ago for a few medical questions that had been bugging him for a while. He had a surgery several years ago (before we were married) that required several deep incisions and required the wound be repacked twice a day until it healed rather than be sutured. Another lingering concern was a rash he'd had for a while that turned out to be a fungal infection, for which he was told to swap out a couple of different antifungal creams, which cleared it right up within a couple of weeks.

He submitted his insurance and went on his way. We get a bill last week. It says "these are non-covered services because this may be a pre-existing condition." Husband calls the doctor and they mumble something and eventually say the rash was considered pre-existing.

First of all, I looked up pre-existing. It's something you've received treatment for in the past. He's NEVER been treated for this rash. And second of all, as of January in the US, isn't "pre-existing condition" generally a moot point? This is insurance through his work, and from my understanding of the law, if they're covering him they cannot deny a claim based on "pre-existing condition."

Apparently the person we really needed to speak with wasn't there today, so he made sure it was okay if I called about it tomorrow (he's notoriously bad at asking the correct questions in these situations). Gonna try to clear things up with the doctor's office and remind them about AHCA and make sure I'm understanding this right. Then I might need to call his insurance and possibly the insurance commissioner for my state. I'm sure they'd be VERY interested to know what's going on and in investigating how many people the company has tried to screw over that aren't as aware of their rights under the new healthcare laws as we are.

Unless I'm completely wrong and misinterpreting the act. Which is entirely possible.

Anyone else have any experience with something similar?

[jedimaster91]

One thing I would make very sure of is whether or not the visit was coded correctly. If not, that might be why it got denied. And with ICD10 on the horizon, they are looking at the coding very closely.

[Kaylyn]

Yeah, I had a coding incident last year when I went to my old doctor for a staph infection (boil in my armpit). They coded it as "fertility" causing insurance to deny it. I told billing, "If that's fertility treatment, I've been going about this ENTIRELY wrong!" We had a good laugh about it and they corrected the error and resubmitted the claim.

It's just dumb because even IF it was coded as pre-existing, that STILL shouldn't matter. I plan to get to the bottom of this tomorrow, at least as far as the doctor's office is concerned.

[Sapphire Silk]

Basically, he went in for treatment for one thing, and got something else he'd had for awhile treated while he was there. So technically, it was pre-existing.

I do think it should be covered under the law as it stands now, but talking to the insurance commissioner in your state would probably clarify things for you.

[paperfiend]

I had an insurance billing issue recently where I went in for my annual physical exam (preventive care) and while I was there they drew blood for a cholesterol test (I have a history of high cholesterol).

The visit should have been covered as preventive care, but since it included the cholesterol test it got coded as diagnostic. Apparently since it happened in one visit, the provider could only use one code so the diagnostic code applied to everything they did in that visit so they charged me for the whole thing.

I wonder if that's what's happening in your case - they can't split out the codes?

FWIW I called my provider's billing department and they agreed to try splitting it out and resubmitting to insurance. The insurance company and the provider apparently got into a stalemate, but the end result is the provider took those charges off my bill.

And now if I need tests for something that's not pure "preventive" I just do it in a separate visit so it doesn't mess up my preventive coverage. Which ends up costing the insurance company more but if that's the way they want to do it...

[Kaylyn]

My husband just called the doctor's office today because I was having a case of phone anxiety and didn't want to do it for him and they're going to call the insurance company and hopefully straighten it out.

[Sapphire Silk]

Insurance companies make money by not paying claims. Be persistent and polite. It may take a few tries.

[strawbabies]

If he had the rash and was diagnosed as having it, that would make it a pre-existing condition, whether he got treatment or not. The ACA just stops insurance companies from being able to completely deny someone coverage because they have a pre-existing condition. However, it does not mean the company has to pay any associated claims for that particular condition right away. They can say they won't pay for anything related to the rash for a year.

[Shyla]

Pre-existing does mean it has been treated before. If I have a rash on my stomach and go to the doctor it is not pre-existing. If I go in a month to the doctor and say the rash didn't go away, it is pre-existing. So it depends if he ever saw the doc before for that rash.

[Argus]

Pre-existing does mean it has been treated before.

In some states, yes. In other states (such as Louisiana), pre-existing means that it was already present before the insurance started and would have resulted in a doctor's visit by a "prudent person".

But as noted already, such exclusions ended on January 1, 2014 for all group health insurance. The only exception is for individual health insurance (i.e., not through an employer) purchased before March 23, 2010.

(Pre-existing car damage can still be excluded from car insurance, of course.)

[Taz]

From my research, the pre-existing exclusion part was removed as far as applying for group insurance. The insurance companies are still allowed a 90 day waiting period from the effective date of the insurance policy.

@Kaylyn - How long before the doctor's visit did you husband receive his group insurance? Also, did he have coverage before that - within the previous 12-18 months?