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Post by carolyn on Oct 26, 2004 7:30:02 GMT -5
John (5) is never ever sick. He bascially sees his pediatrician 1 time a year for a basic check up and blood work. I am thankful for his good health- but ..Last year when I took him in the dr. office ended up charging me for a well child check up which my insurance does not cover for a 5 year old. This year I approached them first and asked if they could bill it differently so I would not have to pay- I maintain that I would not be bringing him in if not for his DS, and that he needs this basic once over and his blood work to establish his baselines. The office manager said she had to bill it this way, the dr. said that what I am doing is bascially fraud (!!) so today I got the bill for $145.00 and I am furious. Previously to moving, I went to a University of Michigan clinic, and I never had to pay for these visits. They billed them as some kind of continuing health care, which is really what it is. I am not a cheapskate, but we pay big for our insurance, and it would be nice to use it. I am mad at the dr., going to switch back to U of M even though it is a much longer drive, but once a year, I can do it. But I am wondering if anyone else has had this experience? I felt like telling that dr. that I could bring him in once a year claiming a sore throat or something, get the exam paid for, and just pay the $18.00 for the blood work. Now THAT would be fraud. UGH.
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Post by justinsmom on Oct 26, 2004 11:55:34 GMT -5
Hmmmmmmm we get the docs' creative juices running quite abit . For instance Alyssa went in for her school physical and the doc checked her eyes using the eye chart and came back nervous and scared, she had us an appointment with a pediatric opthamologist within 3 days, we get there and he tells us that our vision insurance won't cover this as there is nothing wrong with her vision, I'm like uggggggh we can't afford that, he chuckles a little bit and says ok I'll just get in touch with my creative side and he wrote it up as some type of rule out something major based on what the ped found on the initial exam. It sounds like the office just didn't want to be bothered. Our kiddos do need extra check-ups from the neck x-rays to thyroid checks etc....... In fact the state was nice enough to get rid of KidsCare and switch to CSHCS and I had to fight to get pediatricians covered for Justin. They would have rather paid around 3000.00 every 6 months just for thyroid level checks rather than the 190.00 every 6 months for the pediatrician grrrrrrrr well we got that switched REAL QUICK lol . Justin gets the CSHCS because of the ASD/VSD, pulmonary complications and thyroid. Good Luck
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Post by christie on Oct 26, 2004 20:24:17 GMT -5
Hmmmm sounds like a yearly physical to me, although I may have missed something I thought all insurance policys included one physical a year Geez even my daughter, none DS goes in once a year for a physical, which sometimes includes blood work and shots, you know what ever is required at the year she is in and its covered. Hmmm if you don't mind what insurance company do you use?? Just a thought, but maybe you could call the insurance company and see exactly what there polices are on yearly physcials. Believe me insurance companies can screw up, and maybe this is really covered. Best of Luck CC ~
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Post by MB on Oct 26, 2004 20:29:13 GMT -5
Was there any bloodwork ordered that is not ordered for every other typical kid who is 5 and having a check up?
For example, it the bloodwork was to include a check for thyroid levels because the kid has Down syndrome then I think you have a clear case for monitoring of the Down syndrome instead of a well check up.
MB
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Post by Chris on Oct 26, 2004 21:18:30 GMT -5
Carolyn, Where do you live? I live just outside of Detroit (downriver). I certainly don't believe you are trying to commit insurance fraud. I know many insurance companies DO NOT cover well child visits even when they cover yearly adult physicals. A child with Ds does require more testing than a typical child. Some medical professionals would even argue that Ds is a disease. I pay $6,135 a year for my insurance premium and my school district pays the other $6,135. I am furious because my insurance company is trying to weasel its way out of paying for covered services for Sarah. For example, they refuse to cover ot for feeding because they claim the school district should provide ot. They refuse to cover pt because they claim all of Sarah's problems are merely a developmental delay (I guess her low muscle tone and extremely loose joints don't cause any problems). They refuse to cover speech because she hasn't had a loss of speech, it is a developmental delay (again, her low tone doesn't have anything to do with it!). Now, you tell me who is commiting fraud. For those of you who get Medicaid and qualify because of a waiver program, thank your lucky stars. I get so upset when I see other children who have far fewer problems than Sarah get ot, pt and st because they have Medicaid. Boy, this is a very hot topic for me! Chris
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Post by carolyn on Oct 27, 2004 7:46:26 GMT -5
In answer to your questions:
I have Blue Cross Blue Shield PPO ( high end) which is the best insurance we can get through my husband’s job. I am generally pleased with it, I have lots of freedom regarding dr. and hospitals. Heck, they even will pay for John's private speech therapy, which is tough to get covered! My beef really isn't with the insurance company it is with the dr. office who refuses to bill the visit in such a way that it will be paid. I told the doctor it would be negligence on my part to not bring him in once a year for the blood work and basic physical, and as his pediatrician she should want to keep a chart on his growth and development as she might notice medical issues that need to be addressed.
What steams me is that she billed me the full amount of the visit when you know full well if the insurance company paid it would only pay a negotiated price, somewhat less than the charge. I wanted her to at least give me a break, knowing I was going to pay out of pocket. It really bugs me that she is not willing to work with me on this, which means I need to find another dr.
MB: I presented exactly that position to the dr. John has a certain predisposition to a variety of medical conditions, which needs yearly monitoring. If he did not have DS, We WOULD NOT be doing the tests. The presence of DS does make him vulnerable to certain medical conditions that a doctor should be screening for. As his mother I can't see how his ears, throat, heart thyroid ect.. look and sound. The doctor was not impressed with any of this.
Sarah :I live in Tecumseh MI, southwest of Ann Arbor and Saline. Do you know where Cabalas is? I live about 20 minutes west of that. I am thinking of checking out the DS clinic at U of M- anybody know anything about it? I saw something on a U of M website.
Also I have been thinking of sending off my $145.00 with a note as to why I will not be returning to that office. Is it worth my time or will they just not care.
UGH!
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Post by christie on Oct 27, 2004 19:56:59 GMT -5
WOW CAROLYN, I never realized how different all this insurance stuff is
For us I guess we are lucky cause if the Doctor is under the plan then no matter what Chris is seen for is covered and the Doc has to accept what insurnace pays them and cannot bill us for anything other then the co-pay. I have to admit when we first got the plan I was like but luckily every Doc, lab, hospital and such that Chris goes to is under this plan
I am soooo sorry to hear your policy doesn't cover well checks Man you would think all would as they can very well prevent sickness down the road.
Just wondering and again maybe I misunderstood, did you talk to the billing girl or the Doc themselves?? Maybe if you didn't you could talk directly to the Doc.
Best of Luck girl and its not fair thats for sure ~
CC
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Post by alisonzmom on Oct 28, 2004 12:08:07 GMT -5
As a sometime medical biller I can say that changing diagnosis codes just so that an insurance will pay for something is illegal - fraud - and comes with very heavy fines and penalties. And not only does the physician get fined but also the person who did the actual billing!!! That being said, I have sometimes had the clinics at the hospital that I work at go back over a patient's chart to see if there is anything in there that the person doing the coding may have missed that would give a diagnosis code that would be payable. You might ask the docs office to have whoever does the actual coding to go back over the notes from the office visit to see if there is anything that could be added that would help to get your insurance to pay for the visit. I can't tell you how many times this has lead to finding missed codes that then got things paid for!
As for the DS clinic, I think that there are several people here who bring there kids to U of M's clinic - Laura & Cathy???. I did have problem with my insurance the first time Alison went to the DS clinic here. They tried to deny payment because the doc was not her primary care physician/pediatrician. Well, you can bet I was on that phone PDQ!!! Once I made it clear to them that he was in fact a specialist and not "just" a pediatrician, they paid!
Sometimes just threatening to leave a practice can get the results you're looking for too! I wish you luck with all of this!!!
Barb
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