During the time that I was on my parent’s insurance, I was pretty much removed from the entire billing and insurance process. I was lucky in that my dad took care of the paperwork and the phone calls. I lived in my nice little naive bubble where all I worried about was going to my appointments, ordering my supplies, and taking care of my health. I didn’t worry if a certain device or procedure was covered by my insurance, everything just magically worked out. Oh what wonderful times those were.
Then I got a job and my beautiful bubble popped.
I know that I’m very fortunate that my job even offers insurance and that it has pretty good coverage. However, if you ever want to simultaneously raise your blood pressure while feeling like you want to bang your head against the wall, try calling your insurance company to argue a claim.
Take a few weeks ago as an example:
It all started with an email notification that I got that a new claim was available to view online. It was about my most recent routine appointment with my endocrinologist. I followed the link to an EOB. I feel like I should be able to say that I speak “Insurance” since it often feels like I’m reading a foreign language while trying to decipher what is being said. I noticed that the entire bill was higher than the past 2 appointments. Scanning the paper, I found a tiny number leading to the appendix with the following text:
Our payment policy limits the number of times this procedure is allowed and that limit has been met.
Ummm huh??? I went back up to see what billing code this was referring to, thinking perhaps it was some unnecessary test or blood work that I may have unintentionally duplicated.
GLUC MONITOR, CONT, PHYS I&R 95251
Like I said, a foreign language. But whatever it was, I was being charged the entire amount of $120. But if it has to do with glucose monitoring, it probably is necessary. I called my insurance company. The woman explained that the billing code that the limit was referring to was 95251 (side note: I did some googling and this particular billing code can range from $35-$350!). With some simple googling I determined this billing code was referring to the following:
95251: Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; interpretation and report.
Essentially it’s downloading my CGM and interpreting the numbers. At this point I was starting to get both confused and angry. I checked the EOB. I was also charged for an Office Visit so it’s not like it was the only thing they were billing for. But the part I was getting angry about was that downloading and interpreting my numbers is really all my appointments are since checking my a1c and blood work happens at an entirely different time and facility.
I called back the insurance company, asking what the limit of visits are for that code: 2. I attempted to calmly explain that the standard of care for a type 1 diabetic is seeing their endo every 3 months, so 4 visits a year. How could they only be covering half of them?!?!
The insurance woman explained that I’m going to need my doctor to call the patient management team at the insurance company and get the additional visits pre-certified ahead of time for them to be covered and additionally to appeal the charges from the last visit.
At this point I’m just annoyed. But I’m more annoyed at the idea of having to pay so I call the health system starting with their billing department. After explaining the issue, I was told that the doctor will have to call and that it’s something that the billing department can’t take care of. Okay fine.
I call the doctor, the receptionists says I should talk to billing. No, billing said to talk to the doctor. At this point I’m ready to hit my head against the wall. My doctor is not available so I leave a message explaining the entire issue. The receptionists assures me she will deliver the message.
A week goes by. No response.
I call back. The person on the phone looks at my file. He tells me that it looks like it was seen and sent to billing. The person on the phone offers to have someone from billing follow up with me. Yes please.
A few days pass and I finally get a message from someone from Billing. “I see the message in your file,” she says. “It looks like they’re talking with someone at the insurance company. I can call you back when I know more.”
A few more days. “It looks like they are taking off the charge for your most recent appointment.” “That’s great,” I respond “but what about the future appointments? I have one coming up in a few weeks. Are they going to charge me again? The whole point was to get them pre-certified.” “Oh ummm, well I can tell them to look at the September appointment. You’ll have to call ahead of time for each appointment and tell them to contact the insurance company.”
Are you frickin kidding me?!?! Why is this so circular?!?! I thanked her, not sure exactly what was accomplished besides not being charged for the most recent visit. However, the fact that it took almost 2 weeks does not give me much hope if this is the process I’m going to have to go through twice a year, every year!
The funny thing is, I would consider this a successful encounter compared to some of the other arguments and conversations I’ve had with the insurance company. But it’s amazing to me the number of phone calls it takes to accomplish even the simplest task. Working in the health care field and having a masters in public health, I consider myself to be more knowledgeable than perhaps the average person in navigating the health care system. And if I found this process to be arduous, I can’t imagine that many people with much less knowledge are being successful in their efforts.
If anything, I’ve become a much more assertive person through this process, but really I just wish that the whole system was fairer and simpler for everyone.
I share your frustrations. My last endo bill had a line item for “Ambulatory Glucose Monitoring” which wasn’t covered by insurance. I had no idea what it was, but noticed how it hadn’t appeared on any of my previous bills. So I called up the doctor’s office who said they would “look into it.” Several months later, and I have no idea whatever happened with it. From my experience and your explanation, this sounds almost like it may be a bogus charge that doctors sometimes add to invoices when they feel they have a chance at getting paid for it, and when they can’t, they drop the charge.
I hope that’s not the case, and I hope my doctor isn’t playing games when it comes to ethics… but it does concern me.
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