Clerks who make Medical Diagnoses

[Tired_Old_Man 1]

First a little background.

While an employee, I had medical coverage. After almost 35 years, I was laid off because of 911 in 2001. I went on COBRA. I decided on Lap-Band surgery and was approved by the employee medical plan in 2002. I received follow-up care through the medical plan.

In 2003, I relocated about 1400 miles and retired. I am now covered under the retirement version of the same medical plan. The benefits are the same (per the medical plan representatives).

The plan dropped coverage of Morbid Obesity Surgery and all complications from such surgeries last year.

Last year, I had my band tightened a few times and an endoscopy. The endoscopy and band adjustment were done by the only hospital that I could find within 150 miles that took my insurance. They are 101 miles away and insisted on the endoscopy prior to any other treatment. I was having LB's. The insurance paid for the endoscopy, but balked on paying the band adjustment that time and the following ones over the next few months.

I spoke to the insurance company last week because I have been neglecting treatment because of the financial burden. Finally I got someone who would listen and she told me that even though they were no longer covering bariatric surgery or it's follow-up treatment for new surgeries, they were obligated to my follow-up care because the surgery was approved and covered prior to the change in benefits. She told me how to get the new hospital to get authorization to do my post-op follow-up coverage which must be done prior to any more Lap-Band related treatment.

Before I had a chance to call the hospital to tell them what to do, I started having terrible PB and reflux problems. This past Monday morning, I called the hospital and told the bariatric nurse that I was choking on my own fluids even while sleeping sitting up. They made an emergency appointment for me to come in that afternoon just before closing. They emptied my band. By the time the procedure was finished, the clerical help had gone home for the day. I wasn't sure if I would be covered because they hadn't gotten prior authorization prior to be my post-op provider.

Yesterday I had an endoscopy. I told the clerk who handles billing how to get the authorization to be my post-op provider before going for the endoscopy. I told her that I hoped the insurance company would cover Monday's band adjustment retroactively. She said that she would also get authorization for the endoscopy. I told her not to get authorization for the endoscopy because #1, the insurance rep might be wrong and follow-up care might not be coming to me and #2, there is no medical proof that the endoscopy is related to the Lap-Band. It might be any one of many reasons why I have reflux problems. She agreed

About 4-5 hours later, after the endoscopy and after coming back from the induced sleep, I found out that the clerk had given the job of calling my insurance to another clerk, who is more involved with the bariatric department. I spoke to the second clerk. She said that she got authorization for the band adjustment and had also asked and received authorization for the endoscopy. I told her of my concerns. She said that she had gotten it, so we were ok. Suppose that the insurance company had said no.

The doctor did a biopsy for H. Pylori. If it is H. Pylori, then the clerk put me at risk of being turned down for nothing. She had no right to make a medical conclusion that the endoscopy was Lap-Band related. Even the insurance company had not made that conclusion last year when they paid for the endoscopy, but rejected the band adjustments.

[PhotoNut 7]

I swear. This is one of my pet peeves in life. These people DO NOT KNOW ME, they DO NOT KNOW MY PERSONAL SITUATION, they DO NOT KNOW THE HOURS IVE SPENT ON PHONE CALLS to work through the frustrating bureaucratic red tape bull sh*t to get a situation resolved.. so WHY WHY WHY don't they just LISTEN to me and do it like I took the time to lay it out for them STEP BY STEP with CLEAR INSTRUCTIONS and REASONS WHY its so fricking important that they DO AS I ASKED!?

Phew! I feel better now. Thanks.

[Tired_Old_Man 1]

There is an old say: "If you want it done right; DO IT YOURSELF".

But sometimes, you are forced to rely on other people. The insurance company insisted that I was not allowed to make the request, so I printed up a step by step list of directions.

1. Call: 800-xxx-yyyy

2. Select option #2

3. Tell them the name of your institution

4. Tell them my name, ID#, DOB

5. Tell them that you want authorization to do my Lap-Band follow-up care

6. Tell them the follow-up care authorization was previously under xxxxxxxx by zzzzzzzz

Of course, I put the x's, z's and y's in place of the actual words and/or numbers that was supposed to be used. All the information required was on my list. There was no thinking required.

Could it be that when a patient is covered by medical insurance and a visit costs $200, the insurance says the contracted amount is $125 and then they pay 80% ($100) and I pay 20% ($25), but if the insurance company says the treatment is not covered, the facility gets the full $200 from me, so that if the treatment is covered they only get $125 from the insurance company and me combined?

On treatments like surgery, the numbers can even be worse than that. I had orthoscopic surgery one time and the surgery bill was $1500. The company said the contracted amount was $575, so they paid $460 and I paid $115. They received only $575 instead of $1500, but more importantly, I paid only $115 instead of $1500.

The facility' billing clerk has no incentive to work for the patient and the insurance company has no incentive to help the patient.

[Sandybells 0]

Not sure if this could explain why clerks or whatever do the thing...beyond what you specify is that they have to make sure that the correct insurance is paying... First payor or secondary...

Otherwise you or they could be charged with insurance fraud because they didn't file with the correct entity. Just a thought!

[nursekathy2u 0]

Im not understanding why you didnt want her to get authorization for the endoscopy. Did you want to pay for it yourself?? Also, If you come back at H.Pylori positive that has nothing to do with reflux. Reflux is a mechanical problem and is not caused by a bacteria. When a doctor does an endoscopy they will almost always do a biopsy for H.Pylori because they are there anyway and it is pretty prevelant. The reflux may be band related and may not be band related.. the best way to tell if it was band related is if it improved with the unfil.. Not necessarily with an endoscopy. The endoscopy will show it the reflux has done any damage to your esophagus and if there is any other cause for your problems such as slippage of the band or hiatal hernia. So there is no way to know if its band related until you do the test. A catch 22.

[wavydaby 1]

Maybe since she works in bariatrics, she's seen this before and knew who and how to talk to the ins?

[Tired_Old_Man 1]

Im not understanding why you didnt want her to get authorization for the endoscopy. Did you want to pay for it yourself??

My insurance does not require prior authorization for an endoscopy. It only requires one prior authorization to take over my Lap-Band after-care and only because the insurance company no longer allows any weight control (bariatric) surgery. Asking for the authorization for the bariatric follow-up care and then the endoscopy just puts the idea in the insurance company's head that the endoscopy is related to the Lap-Band. As soon as the Fluid was removed from the Lap-Band, my swallowing problem was gone as seen by the flouroscope.

Also, If you come back at H.Pylori positive that has nothing to do with reflux. Reflux is a mechanical problem and is not caused by a bacteria.

As I said earlier, a friend of my wife had a reflux problem and as soon as they found H.Pylori and she was treated for it, the reflux stopped.

When a doctor does an endoscopy they will almost always do a biopsy for H.Pylori because they are there anyway and it is pretty prevalent. The reflux may be band related and may not be band related.. the best way to tell if it was band related is if it improved with the unfil.. Not necessarily with an endoscopy. The endoscopy will show it the reflux has done any damage to your esophagus and if there is any other cause for your problems such as slippage of the band or hiatal hernia. So there is no way to know if its band related until you do the test. A catch 22.

Exactly. So by asking for authorization to do a test that only requires authorization if it IS Lap-Band related, the clerk in effect is saying that the test is Lap-Band related when it may not be. Even it was Lap-Band related, I doubt that the insurance company could prove it or that the doctor could know 100% that it was band related, except if the band had herniated the stomach wall.

[Tired_Old_Man 1]

Maybe since she works in bariatrics, she's seen this before and knew who and how to talk to the ins?

When I explained the "request for authorization procedure" to her, she was totally lost. And she still did it wrong, because all I needed was an authorization to change the follow-up care provider, not a procedure by procedure authorization. My insurance company like many others, routinely denies coverage and holds back payment for mouths. When you are dealing with $300,000,000 in payments per year, a month or two or more of interest here and a month or two or more of interest there can really add up.

[Tired_Old_Man 1]

Not sure if this could explain why clerks or whatever do the thing...beyond what you specify is that they have to make sure that the correct insurance is paying... First payor or secondary...

Otherwise you or they could be charged with insurance fraud because they didn't file with the correct entity. Just a thought!

I only have one insurance, no secondary.

[nursekathy2u 0]

As I said earlier, a friend of my wife had a reflux problem and as soon as they found H.Pylori and she was treated for it, the reflux stopped.

The treatment for H. Pylori includes what is called a proton pump inhibitor such as prevacid or nexium. Proton pump inhibitors decrease the amount of acid in your stomach. This is the same medicine given to treat ulcers, heartburn and reflux. Likely she got better because of the medication and not the eradication of the h.pylori. This is simply the opinion of a nurse .. not medical advice..

[Tired_Old_Man 1]

The treatment for H. Pylori includes what is called a proton pump inhibitor such as prevacid or nexium. Proton pump inhibitors decrease the amount of acid in your stomach. This is the same medicine given to treat ulcers, heartburn and reflux. Likely she got better because of the medication and not the eradication of the h.pylori. This is simply the opinion of a nurse .. not medical advice..

I will ask my wife to ask her friend if she took any other medication besides the antibiotic.

I was taken two Nexiums a day and having the terrible reflux problems.

[Tired_Old_Man 1]

My doctor informed me that I tested negative for H. Pylori.

So in about a month, I will see how my weight is doing and then decide what to do about a fill.