Why can't I get my claim paid?

Question

Back in December, I had my annual ob/gyn visit. Because of some issues, she suggested that I have an ultrasound done to check for fibroids. They were able to schedule it only 2 days later - results showed everything was fine.

The bill was submitted to my insurance company and the charges were applied to my $1500.00 deductible. I asked why this wasn't paid. I was told because it was due to a condition. If it was coded as Preventive Care then it would have been paid. I told them it was done because of my yearly visit.

I called my doctor several times but I always get a call back from someone else - the records department, the nurse, etc. Everyone is going by what the doctor wrote but I don't even know if they have talked to her and explain that my insurance company won't pay anything on this.

Is there anything that I can do to get this claim paid? It seems as though I am going around in circles and not getting anywhere.

Answer 1

Your claim would have  been paid under your yearly physical, but a ultrasound is not a routine procedure for an annual exam.  Most annuals include, pap smear, blood work and mammogram.  

Since your doctor was looking for something because of a symptom, it wouldn't be paid under your annual physical.  If your insurance paid for everything else associated with this visit, I think you might have to pay.

Answer 2

Get personal with the dr office. The next time you call a person make it personal. When they give their name ask something like Hi (insert name) how are you? Tell them what's up and let them know you need help. Tell them you are sure they can help. Ask for their help, and ask if you can contact that specific person for more help. In my experience people want to help more with things like this if you flatter them and stay positive. Making it personal makes them feel more obligated.

Answer 3

It would seem, going by what you have stated, "because of some issues," that the ultrasound was ordered because of a possible existing medical condition. It was not ordered as part of your annual gynecological exam, therefore the ultrasound would be subject to the annual deductible.