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Doctor Billing Vent, Seeking Advice (long)
Ok, so I'm on progesterone shots this pregnancy to stave off preterm labor since C came 4 weeks early. The doctor prescribed the medication and said they order it from a mail order pharmacy so it would be cheaper and it's not normally carried by local pharmacies. Fine, no problem. Then the billing manager at my OB's office mentions that we will have to pay for the drug. What?! I have double insurance coverage. I ask if they will bill both of my insurance companies first and then if it isn't covered I will be happy to pay the bill. She says no, they won't bill the insurance companies because "they never cover this medication." I persist and said if it's not covered let the EOB tell me that, I don't want the doctor's office making assumptions about coverage. Answer is still no. I ask if I can make a claim to them directly and she said yes.
So I order my medication from their recommended pharmacy because I have to start my first shot it less than a week and I start checking with my insurance company about coverage. They said they needed CPT codes and diagnosis codes in order to determine if it would be covered. I call and get this information from the billing manager and again ask why they won't just bill this to the insurance company for me since they already have all of the information. She says they won't. I insist they bill quite heatedly and she just continues to refuse to bill it. I talk to a doctor about it at my next appointment and she backs the billing manger saying insurance never covers it and it's cheaper for patients to get in through their mail order pharmacy.
Fast forward to today. I find out my insurance company does cover it at 100% as long as it is ordered from an in-network specialty pharmacy. Of course the one my doctor had me use is out of network so now I have a $200 deductible and a 30% coinsurance. Then I find out, because my doctor in an primary care in-network provider they are required to bill my claims to the insurance company for me.
Really?!!! Now I am super upset. What would you do? I plan on talking to a doctor again at my next appointment and at least informing them that this is now a "covered" medication and they should really be billing insurance companies for it. Is there any way I'm going to get the doctor's office to cover my $200 deductible and 30% copay? If not, can I file a formal complaint with someone? My insurance company, for the provider not following its contractual obligations? A patient advocacy group here in town? It just burns me up that I was so persistent and everyone just brushed me off and now I have to pay for it. Any advice ladies?
Re: Doctor Billing Vent, Seeking Advice (long)
P17 is frustrating. My OB ordered it through a mail order place, who wouldn't take insurance at all. I had to submit the claim myself. When I did, I did it VERY carefully. VERY carefully. They denied, stating I didn't provide some important #. The same # that was on each of the forms the rx place sent me, which I sent to the insurance folks. Grr! So I called in to give them the # again, and they took it over the phone, and said it would take 2-3 days to get to claims processing, then 7-10 days for an answer, then another week for me to hear back. Awesome. Way to be timely and keep my money. I'm hoping that we'll soon see a check in the mail for reimbursement.
I think in your case I would get something from the insurance company stating that since the OB is in network they (OB) need to bill ins, and that P17 is covered if using the correct pharmacy, and present a copy to your OB, and the billing office, and the person who actually calls in the rx order. Then file a complaint with the OB that you weren't listened to and it's costing you $X.
The same thing happened to me with my last pregnancy. I paid $100 out of pocket for the shots and after a couple of tries with insurance I just gave up and didn't get reimbursed. My time is valuable and I'm not going to spend it on the phone or doing paperwork all day long.
I didn't need to refill my script after I moved here so I don't know what my new insurance would have done.
I went to OB/GYN Associates-I think that is the same place as jeffstaci.
Oh I would be calling and insisting that the doctor call me directly to discuss this NOW.
Because they failed to due their diligence it has cost you money that you would not have had to pay if they did their job. Fine insurance companies NORMALLY do not pay for this - but that doesn't mean that YOURS won't.
I would insist that the doctors office refund me. THEIR ERROR caused this issue.
Oh man, I'm getting heated for you about it. Good luck!
The ironic thing is that syd IS a lawyer, who just happens to work in insurance. I think this doctor's office pissed off the wrong person.
I completely agree w/ Jacks - I'd be all over this situation until I was fully reimbursed. That is utter crap that you were so diligent about getting coverage and they continually turned you away. I would explain to them very clearly that you are extremely upset and would like to get your money back, and they are lucky that you aren't pressing more to be compensated for th etime you lost.
I get what panda is saying about your time being valuable, but I just get so worked up about things like this that I have to say something based on principle. In our old town home when things started going south w/ Regency we were getting screwed on a couple of things. I very firmly mentioned that I was an attorney who was currently SAH and had nothing better to do than to see that justice was served. I very quickly got everything I (rightfully) asked for. I suggest you mention something similar. Good luck!
I guess I wouldn't go so far as to get a lawyer over it (and was chuckling as I remembered also that you are a lawyer) or to change Dr's. OB care is one thing. The office staff messing up is another. It's hard to find OB care that you're comfortable with. My $.02 is that p17 is standard care for ANYONE delivering at or before 36wks in a previous pregnancy and actually IS usually covered. Very standard. There was an issue with the new Makena not being covered due to astronomical prices, but that was fixed when FDA took away their exclusive rights to market p17 and gave it back to compounding pharmacies. I'd definitely raise hell over it and let the office manager know that you expect to be reimbursed for their mistake. However... I'm kind of surprised that the office would be required to submit a claim. I think that gives you a good leg to stand on when mentioning to them that they mishandled that requirement, but generally speaking, Dr offices only submit claims as a courtesy to the patient. Technically (again in most cases) it's the patient's responsibility to make sure claims are submitted etc. but most offices just do it because it's handy for their patients.
Oh I would be so hopping mad. I'm mad FOR you.