By Gail M. Pfeifer, MA, RN, AJN news director
My husband and I both recently had preventive screening colonoscopies, which are now covered under the Affordable Care Act (ACA) as preventive care for adults over 50. That coverage, if you purchased a new health insurance plan on or after September 23, 2010, which we did, means you do not have to pay a copayment or coinsurance or meet a deductible if you use an in-network provider (here’s a full list of preventive services covered under the new law). You would think that medical office billers and insurance companies would know that by now.
Although some plans have clauses that let them off the hook on this rule, ours does not—these tests should have been covered. Lucky for us, we knew it when the bills came in. To make a long story short, I was billed for the “surgery” and for the anesthesia. So I first called the billing department of the GI specialist’s office and asked them to rebill the procedure correctly, as preventive screening. No further bills from them, for me, but shortly afterward, my husband was billed by the same office for “surgery” occurring months later—same doc, same procedure, same billing office. He’s following up with phone calls as I write.
I next called the anesthesia billing office, which said our insurance company had denied the claim. I called the insurance company, which looked at our plan and found that, indeed, anesthesia should have been covered; they promised to issue a new claim number. Three weeks later, I got not one, but three, invoices from the anesthesia biller for the same deductible amount. I called them again, and they explained that, because “it takes 30 days for the new claim number to be received,” and “our system automatically sends” out invoices, I was mailed another bill (although they couldn’t explain the threesome). Seriously?
Call me a cynic, but here’s what I think: Both medical offices and insurance companies know the rules by this point (it’s been more than six months, after all)—but they think that if they bill you often enough, you’ll just give up and pay them. I actually told this to the fellow from my insurance plan (nicely, of course, because he is just the guy on the phone). My comment was met with dead silence, which I took for confirmation.
Even if this is not the case and I need to lighten up and calm down, the whole situation is frustrating and time-consuming for me—a nurse. What happens when our lay patients deal with this? Do they give up and pay? Do they know where to go to find out what new rules are rolling out and when? The ACA is working, but we, and our patients, must know how it works—and what to do when providers ignore the new rules. Visit www.healthcare.gov today, and learn what you need to know to protect yourself and your patients.