I recently learned a lot about problems that can occur between a doctor’s orders and a screening procedure. Questions need to be asked and answered at many levels that include insurance providers, both primary and secondary, and all billing departments that will be submitting charges. Take notes, and write down names of people who gives feedback and guidance, plus dates and times. Get anything in writing when possible.
Recently my primary doctor ordered a screening colonoscopy. It had been a number of years since my last one. My records were in his system and available for the specialist to view. His nurse handed me a copy of the written orders. She said that the paperwork would go to a department that would co-ordinate insurance information, eligibility, and get me set up for my appointment. She added that if I did not hear from that department in a timely manner I should call the number listed on the orders she gave me.
Two weeks passed without a call, so I reached out to get the ball rolling. The person I reached sounded confused when I told her what I needed from her. Her response was, “Well let me give you the number for the doctor’s office, and you can call for your appointment. I called and made my appointment”. A few days later I got a call from the doctor’s office and answered questions, basically a health history, and was told that I would get detailed instructions to follow before my scheduled procedure. There was no mention of insurance concerns during that call.
On the day of my appointment I arrived at a MultiCare facility and their Day Surgery Department. A medical history was again taken without any mention of my insurance coverage.
After being positioned on the procedure table the doctor came in and said, “I want to let you know that this procedure will probably not be covered by your Medicare insurance, because they only approve a colonoscopy screening every ten years, and you are eleven months shy of the ten years.” What I did not know at the time was that my supplemental insurance would not pay anything if Medicare did not pay. I was in total shock at this point. I stammered that I had supplement insurance and was in a financial aid program that MultiCare provided for people in my income bracket. The doctor replied, “Then it is probably ok”, and the doctor and her team proceeded.
The next day I called the doctor”s office and asked to speak to a manager in the billing department. I explained my story from beginning to end. She asked me if I had been asked to sign anything stating that I had been informed that Medicare and my supplemental insurance would not pay for a screening procedure, because ten years had not lapsed, and that I had the option to wait the eleven months needed because of Medicare’s rule. I said no, I had not signed anything and that the Doctor had said my insurance MIGHT NOT PAY. The manager said the law requires that I be informed and sign a release saying I knew all of the facts and options. She told me I would not be responsible for the charges that I was calling about. She added that their system of communication had failed, and measures would be taken to rectify the problem my call had exposed.
I encourage anyone facing procedures or expensive tests, especially screening ones, to ask questions, call their insurance providers about coverage, check out medical records, and ask their doctor’s personnel about limitations, and check with the billing departments and any other parts of the chain of command involved.
I had no idea when my last procedure was except that it had been a long time ago. Had I known I was shy eleven months for the procedure to be covered I could have easily rescheduled. Understand rights and laws involved. I have spoken to several friends, and none of them had heard of the ten-year rule by Medicare attached to this screening procedure. So please be proactive, and do not assume someone else is looking out for your interests.