"Free" Prev Care May Not Be Free

[Yagents]

Excellent article discussing the 3 dangers in getting your preventative care. Boy do I stress these 3 things, but it still puts our butts on the line for disappointment.

“Free†Health Care is Often Not Free | LifeHealthPro

 

[somarco]

Word of advice, NEVER interpret a claim for a client or prospect unless you are reading their EOB.

If some other agent want's to tell folks they get a free everything (including colonoscopy) let them. They can pay for it too once the exam finds polyps and is no longer coded as preventive.

 

[JimmyUt]

Word of advice, NEVER interpret a claim for a client or prospect unless you are reading their EOB.

If some other agent want's to tell folks they get a free everything (including colonoscopy) let them. They can pay for it too once the exam finds polyps and is no longer coded as preventive.

Our local Humana manager made sure to very clearly let us know than anything more than a basic colon screening is no longer preventative. They even mentioned it in their seminars.

 

[ksigmtsu]

The preventive screenings are preventive, if they're not being used to examine someone with a known issue. Even if the issue is FOUND in the preventive exam, the exam is still preventive.

Any treatment done during or after may cause the hospital to code it different, the insurance carrier may try to not pay the claim, but that does not mean they are acting under the law or in good faith.

 

[somarco]

Even if the issue is FOUND in the preventive exam, the exam is still preventive.

You might want to check that. Look at some EOB's where polyps were biopsied during a routine exam that was "age appropriate" for a "free" screening.

Also, if your medical history indicates you have checked off a concern some of the testing that relates to the problem is diagnostic, not preventive.

 

[ksigmtsu]

The eob and the law are 2 separate documents.

They may be in violation of the law by recoding the preventive exam granted under the HCR bill in the middle of the exam and not been challenged on it yet.

 

[JMO Fan]

Once a test is on the list of freebies, it might be nigh impossible to get it removed - even if it's demonstrably harmful.

 

[somarco]

Not sure where you are going with that. Medical coding on the claim doesn't happen until after the exam/procedure, when the claim is submitted.

 

[ksigmtsu]

Not sure where you are going with that. Medical coding on the claim doesn't happen until after the exam/procedure, when the claim is submitted.

What I mean is, the law states a preventive exam is covered. They go in for a preventive exam, which is what the doctor ordered.

If the procedure that was ordered is changed mid process, is it allowable for the insurance company to deny the claim on the basis that the procedure that was approved and ordered was completed with different criteria.

I don't believe it's been challenged, and it wouldn't surprise me in the least to see a class action lawsuit eventually.

If you go to the mechanic, and they tell you they're going to change your oil then end up rebuilding the engine without your permission, they're not entitled to bill you for the rebuild because you didn't approve or request it.

If a preventive exam is ordered, I don't see how they can say they're not going to pay because the exam changed in nature midway through, other than to not pay for everything that was performed AFTER the exam changed, such as removal of a pollup or biopsy.

Like I said, until I see this survive a legal challenge, I'm not sure who is right on it. I'd imagine that the courts will find the insurance companies are in violation of the law, from how I read it.

 

[Dave020]

This is what Anthem Blue Cross CA told me specific to colonoscopy:

"It would be a not cost to the patient so long as it's a screening colonoscopy. If they find anything, that changes from a screening to a diagnostic colonoscopy".