The cost of medical insurance is a hot topic for debate. Over the last few years, I have felt the pinch of increasing insurance premiums and moved to a high deductible plan. You have probably had to make similar adjustments. In this post, I will share one experience that might help you fight some of the spiraling costs of medical care.

I assume more out of pocket costs upfront with a high deductible plan yet there are a few provisions where preventive care is covered 100%. The annual physical is one of them.

It had been several years since having an annual physical. Last year, my doctor said let’s get it on the calendar. Here’s the paperwork to get your blood work. It took six months to get an appointment.

As the appointment approached, I thought I should make a list of things that were affecting my health to discuss with my doctor – some of those minor everyday nagging aches you just kind of deal with. Isn’t that what an annual physical is about – to set a baseline and ward off small things that could snowball quickly left untreated?

At the physical, I brought several of them up. A few weeks earlier I had taken a fall on the ice and landed on my wrist I had broken three years earlier. It was still a little sore and I was getting ready to head to Florida to play some golf. At first he suggested an X-Ray and I opted to wait to see if it got better. He suggested I play golf and if it hurts to stop. If it did not improve, I could revisit the x-ray option upon my return.

The second issue I was experiencing was re-occurring acid reflux. Weight loss, changes in my diet and eating habits (eliminate meals after 8pm) and taking some over the counter medicine would make a big difference. I expected the subject of weight loss to come up during the physical; I had been inching up the scale over the last few years.

A few weeks later, the bill comes in the mail. Since I pay out of pocket first, I scrutinize my bills more closely and notice two office visit charges – $185 and $120 = $305. I called the doctor’s office to inquire; they no longer handle billing so I was told to contact their billing agent.

The billing agent’s response is that they are processing the codes that the physician puts down for them to bill out. It is not up to them to change it. They suggested I call back the doctor’s office and ask them to reconsider what was provided to them.

On my second call to the doctor’s office I asked them to review the billing code with my doctor. A return call said that the billing stood because a diagnosis was made: acid reflux during the physical exam.

I shared my frustration with the office manager. I could understand a separate charge if my health issue required significant time to diagnose; however, our conversation was less than two minutes and I considered a part of the physical exam. Au contraire, according to her, physicals do not include these discussions.

Since when did the definition of a physical change? I have never had this happen before. Who’s responsibility is it to inform the patient that you are now entering into a new visit charge?

The office manager understood my position; I was not the first person to question their practice. Her hands were tied; confidentially she agreed with me.

The next step was to call the billing office again and formally request they review and intercede on my behalf. They said it would take about 7-10 days.

About two weeks later, I decide to call Excellus because I wanted to talk to the ethics department. This situation continued to burn me. I spoke with an informed customer service representative who told me this was not the first time he had heard of extra visit billings. He said the insurance company does not control how the doctor bills. In his opinion, after looking up my records, he agreed the charge was unreasonable.

The next step was to call the billing agent to see if my appeal had been granted. After two weeks, there was no progress or resolution. I informed them that the insurance company had suggested I file a grievance. I told them I would wait awhile longer and if there was no resolution, I would file it.

Here is the information that the insurance company needs if you find yourself in this kind of situation:

  1. Patient’s name
  2. Provider’s name
  3. Date of service
  4. Procedure code
  5. Diagnosis code
  6. Referral number (if applicable)
  7. Claim number (given to you by the insurance customer service agent)
  8. Why you disagree with the contract exclusion
  9. Why it should be covered
  10. Any documents
  11. Notations of calls to all parties involved

Today’s update, it has been 45 days and still no decision. The paperwork is hung up in the system. It seems like a no-brainer to me.