Medical Insurance Coverage Question

[Rpoole8537]

Two years ago, I had a colonoscopy that was not successful because my colon was not sufficiently clear for the doctor to complete the examination. This practice used multiple laxatives to complete the cleanse and this method is known for not being the sufficient. New GP stated that because I am 63 yo I should schedule another exam. I made the assumption that because the first was unsuccessful, insurance would pay for the next one. Should I not be guaranteed one good one? Well, my claim was denied. They paid the doctor but did not pay the facility. Reason given was doctor did not charge for the one in 2017, facility did charge in 2017. I plan on getting the notes from the 2017 exam, and trying to argue my point. I was told I only get one routine exam every ten years. I think this type of preventative exam is required by the ACA. Does anyone know where I might find a copy of the regulations concerning these exams. Also, if they do not pay, how do I go about negotiating a price that is lower than the custom titanium frame price that they are asking for now!
I did call the insurance company prior to the procedure. All she would tell me is that they do pay for routine exams but would not guarantee payment for my procedure. Would not tell me why or under what conditions.
Thanks for all input.

[CNY rider]

What is the source of your health insurance?
Get a copy of your policy and the coverages, and start from there.

[AngryScientist]

What is the source of your health insurance?
Get a copy of your policy and the coverages, and start from there.

good advice. these days, coverage can vary a LOT between different plans and providers.

[2LeftCleats]

That sucks, but not surprised. If a polyp had been found and a scope recommended more frequently than every 10 years, you’d also get screwed because then it would be considered ‘diagnostic ‘ and subject to your deductible, rather than ‘screening ‘, which should be covered. I know that doesn’t pertain to your situation but just demonstrates the stupid system we have. I’d ask the provider what reimbursement they would normally receive if it was covered and see if you can pay that instead of the inflated sticker price. Also, some insurers will not cover an outpatient surgical center but will cover an inpatient facility, or vice versa, so it’s wise to check that out ahead of time. Ultimately it’s patient responsibility to figure it out but I would have expected a heads up from the GI office, since that’s not a rare occurrence.

[eddief]

under medicare for all, i'd be willing to wait rather than dealing with the blood sucking middlemen. but would the govt bureaucracy be any better. i say let's try it. i know someone who does those plumbing jobs for the price of custom steel.

[el cheapo]

One of the leading causes of bankruptcy...unexpected medical bills. Another reason why our Quality of Life is falling compared to all the other industrialized countries. In the U.S. the "$" is more important than the person.

[thwart]

I’d ask the provider what reimbursement they would normally receive if it was covered and see if you can pay that instead of the inflated sticker price.

Yes, hard to believe, but true.

In our crazy system, the uninsured actually pay more.

Another option... don't recall off the top of my head if the ACA covers this, but you may want to consider Cologuard, a newer stool test for diagnosing colon cancer. Cheaper than a colonoscopy, but only an option if you're low risk (no previous polyps and no family history of colon cancer).

Should mention however that if the Cologuard result is abnormal... yep, diagnostic colonoscopy.

[Rpoole8537]

Cologuard would have been a good option. Or, wait one year and I will be on Medicare!!! Too late now as the damage is done.
Getting a copy of the details of the policy will be a good step. I'm retired and on a pension and my medical is included. It's self insured but the plan in administered through BCBS. They stink. My GF has United Health and the information on their website is so much better. I mean light years ahead of BCBS. I cannot talk to anyone other than a "script reader".
I will also get the notes from the 2017 failed attempt, and include that in my appeal. I hope that the group will allow me to pay the "insured rate". If not, I'll go to a different doctor's group for all my future health needs. I had an ablation five years ago and wrist surgery. I need a second wrist surgery and I may need another ablation some day. It would be to their long term benefit to keep me on their group.
I still would like to know what is stipulated in the Healthcare Act. I found at least one article that said specifics are vague.

[rnhood]

The very legislators that had the AHC legislation written don't even know what's in it.

[MerckxMad]

Check your insurance policy terms. Also check your medical record as there should be a note that the first procedure was not successfully completed. The facility can typically bill for unsuccessful procedure. If you didn’t do the prep correctly, your insurer may take the position that the next procedure is not fully reimbursable.