Denied Coverage

JS is on Medicare and has a supplemental plan.  She underwent a breast biopsy of a tumor that was fortunately benign, but after the bill was submitted, both Medicare and her supplemental plan denied coverage.  The reason for the denials was because the mass was benign.  This is when JS reached out to PAA.  The charges were an amount of money JS could afford, but she felt that patient advocacy was needed because the insurance denial seemed wrong and unfair. After all, there was no way to know whether or not the tumor would have been malignant or benign without doing a biopsy.  

We got copies of JS’s bill and medical records and it turned out they had actually billed the incorrect CPT code.  [CPT codes are 5-digit codes that are put out by the American Medical Association (AMA) to describe very specific procedures, which could be anything from giving a vaccination to seeing the doctor for a sore throat or performing brain surgery.]  Our lead nurse consultant faxed a strong letter to the doctor’s office stating that they had not only utilized the wrong CPT billing code, but they had also made the mistake of not to pushing back against the insurance companies. The doctor’s office is supposed to know what procedures are covered and which are not, in general, and they clearly should have asked for the reason why the charges were denied, rather than punt the charges to the patient.  Within a few hours of the doctor’s office receiving a copy of the letter, the office called to say that everything was resolved and her balance was zero – hurrah… hurrah!

This story showcases the importance of pushing back and asking the right questions to the right people.  Unfortunately, it sometimes requires a medical professional or an attorney who can use compelling language to get results in the medical billing landscape, but a layperson can really handle the vast majority of these types of cases.