Dealing with screening versus diagnostic procedures with insurance companies can be difficult and frustrating and I am sorry our services did not meet your expectations The insurance provider, [redacted] , has a policy that physicians must follow when submitting claims for colonoscopies It can become even more complicated as insurers can create different rules for different types of plans they offer What might be considered a screening under one plan may be considered diagnostic under another We looked at the patient’s United plan which dictates if we can bill as preventive (screening) or if we must bill as diagnostic I highlighted the key points in United’s coverage document below Essentially, what this says is that if we are aware that the patient had a polyp in a previous colonoscopy, we must bill it that way Knowingly coding a claim incorrectly in order to benefit a patient or provider is considered fraud and is illegal so we must follow the insurance guidelines For this reason we send each patient a document explaining the difference between a screening and diagnostic colonoscopy Preventive vsDiagnostic Services Certain services can be done for preventive or diagnostic reasonsWhen a service is performed for the purpose of preventive screening and is appropriately reported, it will be adjudicated under the Preventive Care Services benefitPreventive services are those performed on a person who: has not had the preventive screening done before and does not have symptoms or other abstudies suggesting abnormalities; or has had screening done within the recommended interval with the findings considered normal; or has had diagnostic services results that were after which the physician recommendation would be for future preventive screening studies using the preventive services intervalshas a preventive service done that results in a therapeutic service done at the same encounter and as an integral part of the preventive service (e.g., polyp removal during a preventive colonoscopy), the therapeutic service would still be considered a preventive service(meaning the 1st time a polyp is found during a screening colonoscopy it is still considered screening) When a service is done for diagnostic purposes it will be adjudicated under the applicable non-preventive medical benefitDiagnostic services are done on a person who: had abnormalities found on previous preventive or diagnostic studies that require further diagnostic studies; or had abnormalities found on previous preventive or diagnostic studies that would recommend a repeat of the same studies within shortened time intervals from the recommended preventive screening time intervals; or had a symptom(s) that required further diagnosis; or does not fall within the applicable population for a recommendation or guideline (e.g., someone who has a colorectal cancer screening due to a family history) Examples include, but are not limited to: ? A patient had a polyp found and removed at a prior preventive screening colonoscopyAll future colonoscopies are considered diagnostic because the time intervals between future colonoscopies would be shortened? A patient had an elevated cholesterol on prior preventive screeningOnce the diagnosis has been made, further testing is considered diagnostic rather than preventiveThis is true whether or not the patient is receiving pharmacotherapy? If a Preventive service results in a therapeutic service at a later point in time, the Preventive Service would be adjudicated under the Preventive Care Services benefit and the therapeutic service would be adjudicated under the applicable non-preventive medical benefit Preventive Care Services Page of [redacted] Commercial Coverage Determination Guideline Effective 01/01/Proprietary Information of [redacted] Copyright [redacted] Services, Inc
I reviewed the patient's complaint and had our collections manager review her accounts It appears her payment was sent to our previous lockbox It was retrieved and posted to her account I sent the patient a letter on 9/27/to apologize for this situation and to notify her of what occurred and how to prevent it in the future I also left the patient a voicemail so we could discuss the situation Thank you for forwarding the patient's concern
Revdex.com:I have reviewed the response made by the business in reference to complaint ID [redacted] , and have determined that this does not resolve my complaint For your reference, details of the offer I reviewed appear below.[To assist us in bringing this matter to a close, we would like to know your view on the matter.]Regards,Phyllis [redacted] The problem I have with this response is I received none of the information or when I called Madison Medical office, was not told any of the information in the response I am not asking for special treatment, no one was straight forward with me about letting me know that this year Colonoscopy procedure would not be covered 100% in fact I was told the opposite, which is why I called to find out in the first placeAll I wanted to know was this procedure covered, I get all this information now after the procedure but I called before the procedure and was giving none of this information That's why I feel I was not treated fairly by not getting this information when I called and if I was giving all this information, I would have made a different decision and waited the next year when my flex spending money started over
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below.Thank
you for the updated address that I have now given my bank for my electronic payments. However, please explain why I'm still receiving phone calls and emails about late payments days after the payments has already cleared my bank account. The $is a good and recent example, of many examples. For the payment to clear at my bank, Madison Medical has to have received and processed the payment. Why are they still hounding me days after actually receiving and processing my payment? I'm extremely frustrated at having to continually to ask someone to look into this further, it's very indicative of this last year of trying to work with them on this, it's taking far too much of my time and effort and causing stress. Please just check your processes and write me a letter when you've truly fixed the problem. Until then, please leave me alone and stop with trying to blame the problem on me. I filed the Revdex.com complaint so I could get some peace, not to be continually hounded with thisRegards,
Michele ***
Thank you for bringing the concern to our attention. I had our coding director look at the claim and it appears the insurance covered the service but the patient was responsible for co-insurance and the deductible. Attached is a letter that is sent to Madison Medical patients prior...
to the procedure which describes how insurance plans determine if a procedure is covered as screening/preventive or if it is considered diagnostic. I also included [redacted]’s Preventive Care Services policy referencing page 4 which dictates how Madison Medical bills for procedures.
Dealing with screening versus diagnostic procedures with insurance companies can be difficult and frustrating and I am sorry our services did not meet your expectations. The insurance provider, [redacted], has a policy that physicians must follow when submitting claims for colonoscopies. It can become even more complicated as insurers can create different rules for different types of plans they offer. What might be considered a screening under one plan may be considered diagnostic under another. We looked at the patient’s United plan which dictates if we can bill as preventive (screening) or if we must bill as diagnostic. I highlighted the key points in United’s coverage document below. Essentially, what this says is that if we are aware that the patient had a polyp in a previous colonoscopy, we must bill it that way. Knowingly coding a claim incorrectly in order to benefit a patient or provider is considered fraud and is illegal so we must follow the insurance guidelines. For this reason we send each patient a document explaining the difference between a screening and diagnostic colonoscopy. Preventive vs. Diagnostic Services Certain services can be done for preventive or diagnostic reasons. When a service is performed for the purpose of preventive screening and is appropriately reported, it will be adjudicated under the Preventive Care Services benefit. Preventive services are those performed on a person who: 1. has not had the preventive screening done before and does not have symptoms or other abnormal studies suggesting abnormalities; or 2. has had screening done within the recommended interval with the findings considered normal; or 3. has had diagnostic services results that were normal after which the physician recommendation would be for future preventive screening studies using the preventive services intervals. 4. has a preventive service done that results in a therapeutic service done at the same encounter and as an integral part of the preventive service (e.g., polyp removal during a preventive colonoscopy), the therapeutic service would still be considered a preventive service. (meaning the 1st time a polyp is found during a screening colonoscopy it is still considered screening) When a service is done for diagnostic purposes it will be adjudicated under the applicable non-preventive medical benefit. Diagnostic services are done on a person who: 1. had abnormalities found on previous preventive or diagnostic studies that require further diagnostic studies; or 2. had abnormalities found on previous preventive or diagnostic studies that would recommend a repeat of the same studies within shortened time intervals from the recommended preventive screening time intervals; or 3. had a symptom(s) that required further diagnosis; or 4. does not fall within the applicable population for a recommendation or guideline (e.g., someone who has a colorectal cancer screening due to a family history). Examples include, but are not limited to: ? A patient had a polyp found and removed at a prior preventive screening colonoscopy. All future colonoscopies are considered diagnostic because the time intervals between future colonoscopies would be shortened. ? A patient had an elevated cholesterol on prior preventive screening. Once the diagnosis has been made, further testing is considered diagnostic rather than preventive. This is true whether or not the patient is receiving pharmacotherapy. ? If a Preventive service results in a therapeutic service at a later point in time, the Preventive Service would be adjudicated under the Preventive Care Services benefit and the therapeutic service would be adjudicated under the applicable non-preventive medical benefit. Preventive Care Services Page 3 of 64 [redacted] Commercial Coverage Determination Guideline Effective 01/01/2017 Proprietary Information of [redacted]. Copyright 2017 [redacted] Services, Inc.
Since the patient does not wish to return my phone calls, I am sending the patient a letter today and enclosing a copy of the bill and payment which shows where the payment went and where it should have gone. I will stress the importance of updating her bank with the correct PO Box and address so her payments are posted in a timely manner in the future. Again, I am sorry this occurred.
Revdex.com:I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below.[To assist us in bringing this matter to a close, we would like to know your view on the matter.]Regards,Phyllis [redacted]
The problem I have with this response is I received none of the information or when I called Madison Medical office, was not told any of the information in the response. I am not asking for special treatment, no one was straight forward with me about letting me know that this 5 year Colonoscopy procedure would not be covered 100% in fact I was told the opposite, which is why I called to find out in the first place. All I wanted to know was this procedure covered, I get all this information now after the procedure but I called before the procedure and was giving none of this information. That's why I feel I was not treated fairly by not getting this information when I called and if I was giving all this information, I would have made a different decision and waited the next year 2018 when my flex spending money started over.
I reviewed the patient's complaint and had our collections manager review her accounts. It appears her payment was sent to our previous lockbox. It was retrieved and posted to her account. I sent the patient a letter on 9/27/16 to apologize for this situation and to notify her of...
what occurred and how to prevent it in the future. I also left the patient a voicemail so we could discuss the situation. Thank you for forwarding the patient's concern.
Dealing with screening versus diagnostic procedures with insurance companies can be difficult and frustrating and I am sorry our services did not meet your expectations The insurance provider, [redacted] , has a policy that physicians must follow when submitting claims for colonoscopies It can become even more complicated as insurers can create different rules for different types of plans they offer What might be considered a screening under one plan may be considered diagnostic under another We looked at the patient’s United plan which dictates if we can bill as preventive (screening) or if we must bill as diagnostic I highlighted the key points in United’s coverage document below Essentially, what this says is that if we are aware that the patient had a polyp in a previous colonoscopy, we must bill it that way Knowingly coding a claim incorrectly in order to benefit a patient or provider is considered fraud and is illegal so we must follow the insurance guidelines For this reason we send each patient a document explaining the difference between a screening and diagnostic colonoscopy Preventive vsDiagnostic Services Certain services can be done for preventive or diagnostic reasonsWhen a service is performed for the purpose of preventive screening and is appropriately reported, it will be adjudicated under the Preventive Care Services benefitPreventive services are those performed on a person who: has not had the preventive screening done before and does not have symptoms or other abstudies suggesting abnormalities; or has had screening done within the recommended interval with the findings considered normal; or has had diagnostic services results that were after which the physician recommendation would be for future preventive screening studies using the preventive services intervalshas a preventive service done that results in a therapeutic service done at the same encounter and as an integral part of the preventive service (e.g., polyp removal during a preventive colonoscopy), the therapeutic service would still be considered a preventive service(meaning the 1st time a polyp is found during a screening colonoscopy it is still considered screening) When a service is done for diagnostic purposes it will be adjudicated under the applicable non-preventive medical benefitDiagnostic services are done on a person who: had abnormalities found on previous preventive or diagnostic studies that require further diagnostic studies; or had abnormalities found on previous preventive or diagnostic studies that would recommend a repeat of the same studies within shortened time intervals from the recommended preventive screening time intervals; or had a symptom(s) that required further diagnosis; or does not fall within the applicable population for a recommendation or guideline (e.g., someone who has a colorectal cancer screening due to a family history) Examples include, but are not limited to: ? A patient had a polyp found and removed at a prior preventive screening colonoscopyAll future colonoscopies are considered diagnostic because the time intervals between future colonoscopies would be shortened? A patient had an elevated cholesterol on prior preventive screeningOnce the diagnosis has been made, further testing is considered diagnostic rather than preventiveThis is true whether or not the patient is receiving pharmacotherapy? If a Preventive service results in a therapeutic service at a later point in time, the Preventive Service would be adjudicated under the Preventive Care Services benefit and the therapeutic service would be adjudicated under the applicable non-preventive medical benefit Preventive Care Services Page of [redacted] Commercial Coverage Determination Guideline Effective 01/01/Proprietary Information of [redacted] Copyright [redacted] Services, Inc
I reviewed the patient's complaint and had our collections manager review her accounts It appears her payment was sent to our previous lockbox It was retrieved and posted to her account I sent the patient a letter on 9/27/to apologize for this situation and to notify her of what occurred and how to prevent it in the future I also left the patient a voicemail so we could discuss the situation Thank you for forwarding the patient's concern
Revdex.com:I have reviewed the response made by the business in reference to complaint ID [redacted] , and have determined that this does not resolve my complaint For your reference, details of the offer I reviewed appear below.[To assist us in bringing this matter to a close, we would like to know your view on the matter.]Regards,Phyllis [redacted] The problem I have with this response is I received none of the information or when I called Madison Medical office, was not told any of the information in the response I am not asking for special treatment, no one was straight forward with me about letting me know that this year Colonoscopy procedure would not be covered 100% in fact I was told the opposite, which is why I called to find out in the first placeAll I wanted to know was this procedure covered, I get all this information now after the procedure but I called before the procedure and was giving none of this information That's why I feel I was not treated fairly by not getting this information when I called and if I was giving all this information, I would have made a different decision and waited the next year when my flex spending money started over
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below.Thank
you for the updated address that I have now given my bank for my electronic payments. However, please explain why I'm still receiving phone calls and emails about late payments days after the payments has already cleared my bank account. The $is a good and recent example, of many examples. For the payment to clear at my bank, Madison Medical has to have received and processed the payment. Why are they still hounding me days after actually receiving and processing my payment? I'm extremely frustrated at having to continually to ask someone to look into this further, it's very indicative of this last year of trying to work with them on this, it's taking far too much of my time and effort and causing stress. Please just check your processes and write me a letter when you've truly fixed the problem. Until then, please leave me alone and stop with trying to blame the problem on me. I filed the Revdex.com complaint so I could get some peace, not to be continually hounded with thisRegards,
Michele ***
Thank you for bringing the concern to our attention. I had our coding director look at the claim and it appears the insurance covered the service but the patient was responsible for co-insurance and the deductible. Attached is a letter that is sent to Madison Medical patients prior...
to the procedure which describes how insurance plans determine if a procedure is covered as screening/preventive or if it is considered diagnostic. I also included [redacted]’s Preventive Care Services policy referencing page 4 which dictates how Madison Medical bills for procedures.
Dealing with screening versus diagnostic procedures with insurance companies can be difficult and frustrating and I am sorry our services did not meet your expectations. The insurance provider, [redacted], has a policy that physicians must follow when submitting claims for colonoscopies. It can become even more complicated as insurers can create different rules for different types of plans they offer. What might be considered a screening under one plan may be considered diagnostic under another. We looked at the patient’s United plan which dictates if we can bill as preventive (screening) or if we must bill as diagnostic. I highlighted the key points in United’s coverage document below. Essentially, what this says is that if we are aware that the patient had a polyp in a previous colonoscopy, we must bill it that way. Knowingly coding a claim incorrectly in order to benefit a patient or provider is considered fraud and is illegal so we must follow the insurance guidelines. For this reason we send each patient a document explaining the difference between a screening and diagnostic colonoscopy. Preventive vs. Diagnostic Services Certain services can be done for preventive or diagnostic reasons. When a service is performed for the purpose of preventive screening and is appropriately reported, it will be adjudicated under the Preventive Care Services benefit. Preventive services are those performed on a person who: 1. has not had the preventive screening done before and does not have symptoms or other abnormal studies suggesting abnormalities; or 2. has had screening done within the recommended interval with the findings considered normal; or 3. has had diagnostic services results that were normal after which the physician recommendation would be for future preventive screening studies using the preventive services intervals. 4. has a preventive service done that results in a therapeutic service done at the same encounter and as an integral part of the preventive service (e.g., polyp removal during a preventive colonoscopy), the therapeutic service would still be considered a preventive service. (meaning the 1st time a polyp is found during a screening colonoscopy it is still considered screening) When a service is done for diagnostic purposes it will be adjudicated under the applicable non-preventive medical benefit. Diagnostic services are done on a person who: 1. had abnormalities found on previous preventive or diagnostic studies that require further diagnostic studies; or 2. had abnormalities found on previous preventive or diagnostic studies that would recommend a repeat of the same studies within shortened time intervals from the recommended preventive screening time intervals; or 3. had a symptom(s) that required further diagnosis; or 4. does not fall within the applicable population for a recommendation or guideline (e.g., someone who has a colorectal cancer screening due to a family history). Examples include, but are not limited to: ? A patient had a polyp found and removed at a prior preventive screening colonoscopy. All future colonoscopies are considered diagnostic because the time intervals between future colonoscopies would be shortened. ? A patient had an elevated cholesterol on prior preventive screening. Once the diagnosis has been made, further testing is considered diagnostic rather than preventive. This is true whether or not the patient is receiving pharmacotherapy. ? If a Preventive service results in a therapeutic service at a later point in time, the Preventive Service would be adjudicated under the Preventive Care Services benefit and the therapeutic service would be adjudicated under the applicable non-preventive medical benefit. Preventive Care Services Page 3 of 64 [redacted] Commercial Coverage Determination Guideline Effective 01/01/2017 Proprietary Information of [redacted]. Copyright 2017 [redacted] Services, Inc.
Since the patient does not wish to return my phone calls, I am sending the patient a letter today and enclosing a copy of the bill and payment which shows where the payment went and where it should have gone. I will stress the importance of updating her bank with the correct PO Box and address so her payments are posted in a timely manner in the future. Again, I am sorry this occurred.
Revdex.com:I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below.[To assist us in bringing this matter to a close, we would like to know your view on the matter.]Regards,Phyllis [redacted]
The problem I have with this response is I received none of the information or when I called Madison Medical office, was not told any of the information in the response. I am not asking for special treatment, no one was straight forward with me about letting me know that this 5 year Colonoscopy procedure would not be covered 100% in fact I was told the opposite, which is why I called to find out in the first place. All I wanted to know was this procedure covered, I get all this information now after the procedure but I called before the procedure and was giving none of this information. That's why I feel I was not treated fairly by not getting this information when I called and if I was giving all this information, I would have made a different decision and waited the next year 2018 when my flex spending money started over.
I reviewed the patient's complaint and had our collections manager review her accounts. It appears her payment was sent to our previous lockbox. It was retrieved and posted to her account. I sent the patient a letter on 9/27/16 to apologize for this situation and to notify her of...
what occurred and how to prevent it in the future. I also left the patient a voicemail so we could discuss the situation. Thank you for forwarding the patient's concern.