Health Care Reform Works—If You Work It

Medical Bills

Image by urbanbohemian via Flickr

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 today, and learn what you need to know to protect yourself and your patients.

Bookmark and Share

Senior editor/social media strategy, American Journal of Nursing, and editor of AJN Off the Charts.


  1. Cheryl May 26, 2011 at 9:38 pm

    1. Don’t blame the anesthesia billing company…they did NOT ignore the rules. It was YOUR insurance company that did not pay the bill. Why didn’t your insurance company pay…evidently whomever processed your claim didn’t know the rules??? It is YOUR responsibility to ensure payment, not the medical biller.
    2. Not ALL insurance companies pay 100% for a screening colonoscopy (meaning you have not had a colonoscopy within the past 10 years). If you have a history of having a polyp (colon/rectal), the proceedure becomes medical and all bets are off. Your must know the verbage and ask the right questions of your insurance carrier.
    3. Example: Some wellknown policies pay 100% for a screening colonoscopy if you the physician does not find a polyp. If a polyp is found, then the procedure becomes a ‘medical procedure’….you must meet your deductible before BCBS will pay. If you have a $1,000 deductible, then this must be met before your insurance will pay a dime. The same holds true if you’ve never had a screening colonoscopy, but you now have bowel changes, rectal bleeding, etc……this is now a medical procedure and just not screening.
    4. Example: Some insurance companies with WNY and WI in their names do not pay separate for anesthesia services. They only pay for a nurse to give you some sedation. The physician is working on your rear and directing the nurse what to administer….and not ALL of these nurses are Registered Nurses….
    5. Example: At least one HMO will pay 80% or 70% of the cost for a screen colonoscopy without finding a polyp, however your are responsible for meeting your copay. This means that this HMO policy will only pay 80% or 70% while you must pay 20% or 30% out-of-pocket.
    6. The insurance companies have gone to a great deal of trouble to get around paying for colonoscopies. They work the policy to their advantage.
    7. As a consumer of healthcare, each patient needs to take responsibility for seeing if their insurance company will pay PRIOR to any elective procedure/surgery (remember however; the insurance company will not guarantee payment of anything prior to the procedure/surgery).
    8. The days of having the doc file your insurance and you never getting a bill are over (so is paying your bill over time). You pay when you buy groceries and pump your gas. The same now holds true for healthcare. You’ll have to prepay your deductible to the hospital, physician or whomever PRIOR to any electibe procedure/surgery.
    9. Finally, don’t complain to the insurance guy on the phone. Call your state’s Insurance Commissioner…he/she is the person you need to talk to…not the claims processer.

    40 Years in Anesthesia
    (sitting on the stool {meaning I actually work giving aneshesia} and beating my head against a wall with insurance companies…and patinets expecting me to work for free or spend my every free moment trying to get their insurance company to pay for their anesthesia)

  2. Lois Roelofs April 22, 2011 at 5:25 pm

    My thoughts exactly. I pity the layperson who doesn’t have the savvy to fight or wade through the billing systems.

Comments are moderated before approval, but always welcome.

%d bloggers like this: