MEDICAL INSURANCE QUESTION! Insurance refusing to pay! Please help!?

Question

My friend was insured with a company last year and went to her OB GYN for a routine examination. She thought she was getting a pap smear, but now, a year later, she gets a random bill for over $300 in the mail. She called to straighten everything out and she was informed that her insurance was not covering the HPV screening the doctor performed on her. She told her doctor that she never asked for or authorized an HPV screening, ONLY a routine exam and pap smear. The office informed her that they perform the HPV test on all women under 30 and that most insurance companies pay for it, but her insurance company did not. Is this fair? Lauren didn't even know that she received an HPV screening and no one informed her of anything. The other thing is that Lauren had an HPV screening 2 years ago and the test came back positive! So she would never have authorized this $300 test in the first place. This seems really wrong. Any advice? Does she really have to pay for this test?? Thanks for help!

Answer 1

Yes, she has to pay for it.  I'd suggest she appeals it with her insurance company, but likely, it's too late.

Answer 2

If your friend was already positive, it should have been on the medical form she filled out about prior medical conditions. If she doesn't remember filling it out, she can go and ask to see her records. She may even want to get a copy, at least a copy of that form, but that will probably cost her a few dollars.

With that form in hand, or her record nearby with the form and information on it, ask to see the doctor. Not an appointment, and if you want you can explain you believe the doctor may have not done something correctly, and you need to ask about it to clear it up. If they ask if they can help, smile politely and say it's a quick question, but one only the doctor can answer. Be prepared to wait.

When the doctor finally pops their head in, explain that since your forms showed that you were already positive when you walked in, why would they have done the test? Ask if it could have been a mistake on the charge sheet.  Be polite and calm. They may just apologize and have it removed.

If they are unwilling to deal with it, or have no good explanation but won't have it removed, go to the billing office and ask to speak with the person in charge. Explain again that since the answer was on the chart, there was no need to do a test. Either a test was done on her for no good reason, or there was a mistake and they sent a claim for a test that wasn't done. If they try to blow her off, tell them that if this cannot be settled, than you feel no recourse but to contact the insurance company and put in a complaint that they are sending in fraudulent charges.

And insurance companies will call the doctor's offices when one of their members has a complaint. I worked in medical billing, and it happened. Insurance companies want to keep your money rolling in. I would have a copy of the medical form handy in case they would like you to send or fax them a copy.

I can't guarantee they will remove the charge, but there is a very, very, good chance. Performing erroneous tests on people is unethical.

Answer 3

Her dispute is with the doctor, not the insurance company.  She will have to pay unless she can get them to waive it.

Answer 4

First of all, I can tell you that "most" insurance companies do not pay for routine HPV testing for women under the age of 30.

(If your friend needs some documentation to help prove that point, here is an excerpt from Aetna's Clinical Policy Bulletin on Cervical Cancer Screening:

"Aetna, however, does not cover HPV testing as a screening test for cervical cancer for women less than 30 years of age because the evidence is insufficient to determine whether HPV screening reduces the incidence of or mortality from invasive cervical cancer. Aetna's policy is consistent with updated recommendations of the U.S. Preventive Services Task Force (USPSTF) (2003). The USPSTF concluded that the evidence is insufficient to recommend for or against the routine use of human papillomavirus (HPV) testing as a primary screening test for cervical cancer. The USPSTF found "poor evidence to determine the benefits and potential harms of HPV screening as an adjunct or alternative to regular Pap smear screening.""  http://www.aetna.com/cpb/medical/data/40...

)

Now...for the second part of my answer:  Does your friend have any financial recourse?  It depends.  The insurer isn't going to cover it, so there's not much point in debating it with them.  She could try to negotiate with her doctor.  Here's a couple of questions your friend should think about...

1)  Did the doctor's office give her any literature on their standard policies and procedures?  If so, did that information include any disclaimers about the fact that they always do an HPV test with each pap smear?

2)  Did the doctor and/or his staff verbally mention anything about an HPV test?

3)  Did your friend sign a waiver as part of the office paperwork agreeing to pay for expenses not covered by insurance?

If any of the above 3 points apply, they may weaken your friend's argument with her doctor.  (Yes, doctor's give us lots of paperwork to sign and literature to review...but its important to read and understand it all, to know what we could be getting into financially!)  If none of the above applies, then your friend may have a stronger argument with the doctor to argue that she didn't consent to the test and therefore shouldn't be financially liable.

Good luck...hope it goes well for her.

Answer 5

Tell her to tell the doctor that she "had an HPV screening 2 years ago and the test came back positive! So she would never have authorized this $300 test in the first place."

It's no different than going to Jiffy Lube and finding out after the fact that they changed your differential fluid (which is the closest analogy I could come with) without your permission.  Tell the doctor that they're going to have to eat it.

I had a surgery in the doctor's office and my copay was supposed to cover it since it was done in his office.  But, the doctor (and other's) have a separate bill go to the insurance billed under a "surgery center" from a different address.  If it's done in the surgery center then I actually would have had to pay 20% of the surgery in addition to the copay, because then they can bill a fee from the "surgery center."

Nonetheless the doctor billed me for the 20% and I called them up and told the that it was done in their office and should've been covered by my copay.  Naturally, since what they were probably doing was illegal...or at least unethical, I never heard from them again.

Tell her good luck and be firm.

Jeff