Colonoscopy Not Covered. Should we challenge this?

[BlueStarryHat]

I had my first colonoscopy in my early 40s because my Mom died of colon cancer at 59, after being diagnosed at 53. My insurance is thru Medicaid, and I had to jump through hoops to get them to okay it, like I jump through hoops every month getting them to okay my cholesterol medication. It's part and parcel of being in the system. They denied the colonoscopy once and that was that. I tried to get one at 40 and that was denied and my doctor tried his hardest to get them to authorize it, with no luck. I was denied again a few years later despite my history, but this time when I fought it they reversed the decision. Turns out I had pre-cancerous polyps, which were removed. Now I get a colonoscopy every three years.

 

[Dznypal]

what I don't understand is that if they remove a polyp wouldn't that be preventive--after all its preventing cancer from starting

so far Ive had 2 the first one they found a polyp remove it and all was good--we had good insurance and all was covered but seeing it was the first one I guess it was diagnostic so went for one this year--almost died since according to the dr that day when he talked to my DH while I was still out I stopped breathing not once but twice--but only for a short time--yet when I found out I called for the drs notes where he wrote "pt had 2 brief episodes in which 2 stats dropped into the 60s Narcan was given"

Narcan is given to reverse drug ODs so now Im really upset was it really that I stopped breathing or just 2 stats went too low--to me theres a big difference in not breathing and low stats--

anyways sorry for getting off subject--I get rather worked up thinking what could have happened

so since I had 1 polyp the first time I now have a history -I thought I history was more then just once--so of course insurance didn't cover--well to be fair they covered some and we still got stuck with over 1700$

tried to fight it but no go so if you don't have any problems whats the deal with preventive if you have no problems theres nothing preventive about it but if they take a polyp out that would be preventing cancer

I believe insurance want people just to die so they don't have to cover then anymore

just like that car insurance ad you keep paying your premeums for years and tap one little bumper and up go your rates--DH just got his first speeding ticket in 45 years of driving and the first thing the ins did was raise us

well we finally did what weve been talking about for a long time and switched ins--sure felt good to dump the old com

again sorry for the rant its just when you find out you stopped breathing or as its in the drs notes stats went too low its a little unnerving

good luck to you OP

 

[zoo2tycoon]

Hope you get it worked out. My husband had issues in 40s so had a colonoscopy. We had to pay for that one . Had one a couple years ago at 50 and because of previous one we had to pay. I would pay no matter what- I lost a dear friend 9 years ago who had no history to colon cancer. I promised her when I hit 50 I’d get mine. I did and yes the prep isn’t fun but the test is worth it. I tell my friends to get one when they are 50- my kids godmother had one and found she had precancerous polyps. No history or symptoms. Just did because I kept telling her to after another good friend of mine diagnosed with colon cancer this summer.

OP glad your husband did it . Hope it works out billing wise !

To everyone else get a colonoscopy! Don’t let the prep scare you off!

 

[smokeyblue]

what I don't understand is that if they remove a polyp wouldn't that be preventive--after all its preventing cancer from starting

so far Ive had 2 the first one they found a polyp remove it and all was good--we had good insurance and all was covered but seeing it was the first one I guess it was diagnostic so went for one this year--almost died since according to the dr that day when he talked to my DH while I was still out I stopped breathing not once but twice--but only for a short time--yet when I found out I called for the drs notes where he wrote "pt had 2 brief episodes in which 2 stats dropped into the 60s Narcan was given"

Narcan is given to reverse drug ODs so now Im really upset was it really that I stopped breathing or just 2 stats went too low--to me theres a big difference in not breathing and low stats--

anyways sorry for getting off subject--I get rather worked up thinking what could have happened

so since I had 1 polyp the first time I now have a history -I thought I history was more then just once--so of course insurance didn't cover--well to be fair they covered some and we still got stuck with over 1700$

tried to fight it but no go so if you don't have any problems whats the deal with preventive if you have no problems theres nothing preventive about it but if they take a polyp out that would be preventing cancer

I believe insurance want people just to die so they don't have to cover then anymore

just like that car insurance ad you keep paying your premeums for years and tap one little bumper and up go your rates--DH just got his first speeding ticket in 45 years of driving and the first thing the ins did was raise us

well we finally did what weve been talking about for a long time and switched ins--sure felt good to dump the old com

again sorry for the rant its just when you find out you stopped breathing or as its in the drs notes stats went too low its a little unnerving

good luck to you OP

The narcotic slowed your breathing to the point that you were truly "not breathing" for periods of time long enough to drop your O2 sat to a dangerous low of 60. The number you should have been looking at to gauge "not breathing" was your respiratory rate. The doctor surely did the correct thing administering Narcan. If he didn't it would be negligence.

 

[robinb]

I went thru this, the insurance adjuster was in Malaysia, if you get the picture. You need to send it up the ladder. Preventive colonoscopy is 100% covered, it is the law

Yup! Under the ACA. Keep up the fight OP. All of mine have been covered 100%.

 

[smokeyblue]

Husband is 48 years old. He saw a new physician for a physical and the doctor said he should get a colonoscopy due to his father’s death due to colon cancer. Colonoscopy is scheduled. Office doing procedure says it will be $40. That is it. Procedure was a breeze. No polyps found. Come back in 5 years.


We received a bill from the office. It is our deductible and then 15% on top of that. Called insurance company. Lady on phone says “Must be a mistake. Let’s put it in for review”.

Letter comes yesterday saying “Non-routine Colorectal Cancer screening is processed at 85/15 subject to deductible”.

Non-Routine?


Grrr. He would have waited until January to have this done had they been more clear on this. Why was this non-routine if doctor suggested it for preventative screening? He is not 50. But even office doing it said it would be $40, and they had access to his age.


So, insurance experts, does his father’s death from colon cancer make this a preventative scope?


Is it even worth it to challenge this decision?

The same thing happened to my mother, but she was billed for the entire amount to the tune of a couple grand. The doctor coded the procedure incorrectly, subsequently left the medical practice and the hospital was not able to legally change the documentation. My dad fought them tooth and nail for years. After a few years the hospital wrote it off.

The worst part of this all is that my mom absolutely refuses to go to the doctor now at all. She has some chronic health issues that could surely use attention, but she just wont go no matter what. She wouldn't even go to her "Welcome to Medicare" physical, which was free and they had to pay $50 for not going. Hopefully we can work on her some more and maybe get her to go when they are in Florida for the winter at a hospital that is not affiliated with the one at home.

 

[andy117]

I'm having my first Colonoscopy next month for the same basic reason as the OP. Absolutely fight. Insurance companiy profits are built by people who don't fight enough. Doesn't mean you'll always win but make it difficult for them.

 

[Dznypal]

Thanks for the easy to understand answer you seem to have a good understanding on this. Do you have any idea how long it takes for a narcotic to drop the the stats so low thanks for filling me in

 

[Shanti]

Insurance companiy profits are built by people who don't fight enough.

This. I won't bore anyone with all the details, but suffice it to say that once I had to use a health insurance company that obviously made its profits by being obstructionist about paying out. I never needed a lawyer to get paid in the end, though. Just a ton of persistence.

Follow the steps. Make the calls. Send in the written documentation. Wait. Follow up. It took about a year, but I got the payouts I was owed eventually. I'm sure most customers would have quit after the 2nd try with that company's customer disservice department.

 

[MrsPete]

Sliperly slope.

Our society works because we have rules and people know and follow the rules.

You are advocating for anarchy.

If you don’t like the rules, protest the rules in a legal manner. Don’t commit fraud in the name of good.

If I thought insurance companies were about anything except their own bottom line, I'd agree -- but I don't see any inroads for individuals to make any changes. I'm arguing that insurance companies purposefully use the proper "terminology" to avoid paying claims; individuals should use that same "game".

Regardless, it's hypothetical for me. I have no unpaid medical bills at the moment. This whole year I've been to the dentist once and the OB/GYN once -- both just checkups.

what I don't understand is that if they remove a polyp wouldn't that be preventive--after all its preventing cancer from starting

That makes perfect sense. The insurance companies just play games with their terms.

 

[cobright]

Fight every time the insurance denies a claim. Call for reviews every time. Send in your reasoning via certified letter and tell them you are appealing the claim via certified mail only. Slow the system down. As long as you have an appeal going they won't get paid and can't pass it off to collections. Likely the denial was triggered (correctly or not) by an algorithm in the first place and putting up a token of resistance may be all it takes for a human to just reverse the denial and let their machine move on to low hanging fruit.

Most insurance companies set a lower limit for the percentage of claims that get flagged for denial. Never mistake an insurance company for something with a soul.