Did you know that some insurance companies have a disclaimer that just because their phone rep says something will be covered, it might not actually?

I ran into this recently. I wanted to get my 14-year-old daughter the HPV vaccine. I checked my benefit page (this is BCBS) and it read that only women 17 and older are covered for this vaccination. I thought this odd because it is recommended for girls to get it much younger (it helps prevent cervical cancer among other things). So, I called, and the rep told me it was a mistake and that 17 and older are actually NOT covered. So I got the vaccines, and subsequently received bills totaling hundreds of dollars from the clinic because BCBS declined the charges. After I called back, I found out about this disclaimer. Apparently they are allowed to tell me something is covered when it might be denied.

I will fight this to the death, BTW, on principle if nothing else.

Nick should threaten to file a complaint alleging fraud. Because that is what is was. I'm sure they knew full well the insurance company wouldn't cover it. How could they not know?

@deadandy: An insurance company can have that policy, but it won't stand up. If I call my company, I am speaking to an agent of the company. If they claim that something is covered, the company must abide by the agent's contracting.

That's the core of it.

Granted, you'd have to go through arbitration, have proof you were told that (such as maybe calling while on speaker phone with the doctor there) and then a bit of luck to get through it.

I would definitely take this up with the provider. If the provider is part of the insurance company's network they may have to eat the charges, unless they had the member sign something ahead of time stating that the member knows the services are not covered but will pay for them anyway. (Doesn't sound like this happened)

Here in MN, the provider can't just give the member a blanked waiver either. They have to be specific in which charges they are signing for.

"Claims are determined when claims are received by the insurance company. A verification of benefits is not a guarantee of payment." That is what I'm forced to listen to every time I check benefits for a patient. Even if a service gets pre-authorized, the insurance can still deny it for all kinds of "reasons." Their most popular is for pre-existing condition.

What I would like to know is what the X-rays were denied for. It's possible that the patient has coverage for X-rays, but not for X-rays done by a chiropractor, or not for X-rays of his back due to pre-existing.

Also, unfortunately, it is your responsibility as a patient to know what your benefits are, like he says. I call as a courtesy for patients, but I am not required to.

So is there any way to find out for sure if a procedure is covered if you can't even trust the phone rep? I've always found that BCBS tries their damnedest to make their actual printed policies as confusing as possible.

The whole insurance industry gets me so steamed every time I deal with them.

Why the hell do I have HEALTH insurance if they won't cover everything I need related to my HEALTH?? Why do I have dental insurance when I am constantly getting bills from my dentist for amounts the insurance won't cover?? It is infuriating.

And as an aside, my mom swears by her chiropractor. She has had chronic hip/lower back pain that they have pretty much helped her get rid of.

@Bellatrixie: My favorite pre-authorization EVER was for my baby, when the insurance company sent me a letter stating that they had examined my case and decided that giving birth was, in fact, a necessary medical procedure and I would be allowed to go ahead.

I was like, "THANK GOD, because I don't think he's going to stay in here past his sell-by date!"

"@deadandy: The lease for my apartment has a clause that basically says "if anyone told you anything verbally, and it's not in this contract, it's void. I always thought it was a weird CYA kind of thing ...

At the risk of turning up extra-crispy...

Quite frankly, I don't believe the doctor's office should shoulder the blame alone here. Consider: this office probably has to deal with a dozen insurance companies, each with their own coverage levels, deductions, co-pays, etc. Now, the nurses who typically handle these things know what is generally covered, and most insurance companies will cover X-rays in some form, but not usually elective procedures.

Does this suck? Yes, yes it does. But is it that nurse's fault that she doesn't know all the intricacies of your policy? No, no it is not.

That, Nicky boy, is your responsibility. And while we're at it, Nick, let me explain something about most health insurance policies: they will never cover elective anything unless your primary provider (the general practitioner or other doctor you see most often) recommends it. Yes, that also sucks, but seeing how high costs have become with that restriction in place, imagine what costs would be like if 300 million hypochondriacs went to a specialist (like a chiropractor) without it...

Although Nick's rage against holistic and alternative medicine seems a little misplaced - most insurances cover chriropractor care - he does have a point about checking with insurance companies before you sign off on any elective procedures.

I'd just like to point out that the fact that insurance covers something is not even close to evidence of its legitimacy or efficacy. A lot of insurance companies love alternative medicine because it's cheaper than real medicine, and they know that offering it will divert some people from going to doctors and towards cheaper alternatives (which is fine if you aren't really seriously sick in the first place, but not so great for something serious). Keep in mind that the insurance companies' goal is to save money on claims, not promote your good health.

Chiropractic for back pain only is a little more legitimate than a lot of alternative medicine, but there is a LOT of snake-oil alternative medicine. Don't assume it must be proven just because your insurance covers it or promotes it.

This advise is a bit overrated. At least in Ohio, the ONLY determination of benefits that matters is the one made by your insurance company AFTER the bill has been received by them - that is, AFTER the procedure has been performed.

In fact my battle with CIGNA was covered on consumerist.com a couple of years ago before Ben banned me without warning for saying "yawn" one time, and what I learned then, from the Ohio insurance commission, is that predeterminations of benefits are non-binding. Which means it's not even really insurance, it's a guesstimate. You can get a favorable pre-determination prior to a procedure, but if your insurance company changes its mind after the fact, you're stuck with the bill.

By all means, call and get a predetermination for all procedures, but don't be fooled into thinking you're protected against the risk of non-coverage. You're not. Health insurance companies are scum.

Thank God We have Saint Obama to save us from this mess. I hope you noticed my sarcasm.

I'd recommend Nick try to talk it out with the chiro to get the payment reduced. I'm not sure how well it'll work, but it's worth a shot.

Also, I highly doubt the chiro deliberately deceived him into thinking that he would be covered when they knew he wouldn't. In my experience, medical providers like insurance much more than they like trying to get money from patients.

@TCama: With written contracts, actually that's the norm, the four corners rule. When parties have a written contract, that trumps any oral arrangement otherwise stated.

See [www.law.cornell.edu]

A lot of people don't understand health insurance. Many factors go into whether something will be covered. 1. Is the service covered by the plan? For instance, some plans cover fertility services, some don't. 2. Is the service covered out-of-network? Some services may only be covered if contracted providers bill for it. 3. Is the service medically necessary? Even if a plan covers x-rays, it won't cover them if they're not needed in the opinion of the doctor at the insurance company. 4. Was the service pre-approved? Some things, like appendectomy, may only be covered if the insurance company approves it ahead of time.

Those are the biggies but there are other issues. Is other insurance involved say in a traffic accident? Did the patient leave the hospital against medical advice? Was it a true emergency? &c.

@johnva:

A lot of insurance companies love alternative medicine because it's cheaper than real medicine

I was kind of thinking $280 seemed low for an Xray, at least compared to what I'd think the hospital would charge.

@CaffiendCA: the problem will be you have no proof that the agent actually told you that unless you recorded the call, with no call, you have no case. A lawyer might able to subpoena the call recording, but the company could get around that by either claiming they don't record all calls, only a sample for QA purposes, or saying they delete their call records after X number of days and your call is no longer on file.

@Tom Castle: Excellent post.

Have you considered physical therapy? Your insurance may cover PT services, and depending on your area, you may find a PT that specializes in back pain.

This doesn't help you with your current problem with the chiropractor, but it may help you resolve the trouble with your back.

@deadandy: I would check that this "phone rep's word doesn't count" thing is even written into your policy. Because it kinda sounds like the sort of "policy" that someone in the claims department just made up.

@dragonfire81: Luckily for me, and unluckily for them, I record all calls I make to customer service agents and advise them at the beginning of the call that I am doing so.

I had a chiropractor do the EXACT same thing to me about 10 years ago. After going around and around with the "Doctor" I ended up sending him a certified letter containing the letter explaining the situation, the payment I would have made had it BEEN covered by my insurance, and a barely veiled threat that I would take his ass to court for fraud over this. I may have mentioned newspaper editorials I was going to write and calls to the other local media if he didn't do the right thing. ;)

I recently went to a chiropractor for the first time, and also had X-rays done. However, they actually called the insurance company to verify coverage. Here's the rub...

They said yes it is covered, with a $20 copay. But I recently discovered I'll be getting a bill for an additional $250 (suspiciously close to your amount.) This is my deductible amount, after which these services are covered 100%. Do YOU have a deductible that you have not yet satisfied? I had four Xrays done, and let me assure you that the amount is well over a couple hundred bucks.

So, my question to you is, did your insurance cover a portion of it? Are you left with a 10% or possibly a deductible you must satisfy first?

@CaffiendCA:

I deal with written contacts, and they have a section where those signing must put anything that influenced their decision that's not in the contract in writting, or write word "none". Basically to prevent the who "well he told me i would get a 10% discount even though i signed a contact stating 5%.

So chiropractors are (medical) doctors now? When did this happen? That's always been my strongest argument against going to one.

They probably made an honest mistake, but that doesn't change the fact that he probably wouldn't have gotten the X-rays if he knew they wouldn't be covered. It would be reasonable to expect the chiropractor to give him a substantial discount on the X-rays. Unless the inaccurate information came directly from his insurance company.

Insurance is a shameless scam, that has spread to become a requirement just to get minimum healthcare...

We don't have healthcare in this country (USA) we have sick care.

Don

@CaffiendCA: And presumably letters written after the fact too, because we've had situations where we've received a letter of approval from insurance for a requested procedure only to have them come back six months after the procedure with some clause trying to retroactively deny.

@Bellatrixie: My PPO refuses to discuss claims issues with patients, and the insurance company says they cannot verify coverage until contacted by the provider.

So sometimes we CAN'T check ourselves.

@John Henschen: Explain to us again how it is the Chiropractor's fault that your insurance didn't cover the cost of his services?

@shepd: They are not medical doctors but they are medical specialists. Referring to them as a doctor is moreso regarding their education (D.C. Doctor of Chiropractic).

As a chiropractor, I am getting a kick out of these replies. Your insurance policy is YOUR policy. It is up to you to know what is covered and not covered. It is not so simple to say, "X-rays are covered". You need to factor in deductables, co-pays, etc. Also, your insurance company may not be paying because they were taken by a chiropractor. This is discrimination, and your beef should be with your insurance company, not the chiropractor. On the other hand the chiropractor should not have "assured" the patient the X-rays are covered, and just stated the X-rays are required for a proper diagnosis.

On a side note, chiropractic is a very cost effective treatment for back pain. Several hundred dollars for chiropractic care, compared to up to 100K for the medical alternative of spinal surgery. Although neither will fix all patients with back pain, it only makes sense to me to attempt the least invasive, and most cost effective option first.

Patients effectively have no guaranteed way of confirming coverage, because even with a letter of approval for a procedure, insurance can retroactively deny coverage. It has happened to us. It obviously happens enough that California is considering legislation about it.

I'm in a fun situation right now where I did what due dilligence I could prior to a procedure (given that my PPO won't discuss claims with patients and the insurance company requires the provider to bill first before they'll discuss it with the patient), and was told the cost would be X as a portion of deductible. After the procedure, the provider suddenly upped the charge to X+Y. After a gazillion calls, it looks like what happened is my PPO has allowed a third party with whom I have no relationship to add on this extra charge. Again, the PPO will not talk to me. The insurance company says it's out of their hands. The provider at least agrees that there's no way this third party should be involved and advised me to report it to the state authorities, which I did, and it's now in their hands.

But given such things, really, how the heck are patients supposed to make informed decisions about anything when the information can be changed any time by the other players? It's like dealing with Darth Vader and being told to pray they do not change the deal any further!

Sorry, is it correct to call a chiroptractor a "doctor" i.e. M.D.? Is that allowed?

@shepd: whups I just saw your comment after I added mine.

Seconded.

@Brent Woodle: Because it's assumed that the Chiro told John Henschen that his X-rays WOULD be covered and J.H. believed him.

@Tom Castle: Ohmigod, you said "yawn" again. Could you please refrain???

@mariospants:

Yes, a chiropractor is a doctor. Chiropractors are known by "D.C." Doctor of Chiropractic, not M.D.

Other professions that are "doctors" but not MD's include, dentists, podiatrists, osteopaths, and PhD's

@mariospants:

The chiropractor is not an agent of the insurance company and it is the consumer's responsibility to know that. In situations like this you should assume good faith - no medical provider has an interest in lying to a customer about what their insurance will and will not cover.

@mariospants: Do you call people with Ed.D's and Ph.D's doctor?

@PencilSharp: Let's not get all authoritative when you don't know what Nick's plan is. My HMO plan, for example, allows me to go to a chiropractor without approval from my PCP.

Pay it and take the doctor and the nurse personally to civil court to recoup the funds.

I've called an insurance company before to ask if something was covered and the response was, "just get it done and we'll tell you if it's covered when you submit the claim..." which seems unreasonable to me...

@Brent Woodle: No, and I doubt most chiropractors even have PhDs

@kaceetheconsumer: Yes, you can do EVERYTHING right (you do your research with calls and website searches; the facility/doctor does everything right and gets an answer from the insurance company with regard to coverage) and you can still end up getting a big bill -- on top of the HUGE bill you're already paying for the insurance in the first place! We're going through a problem right now with a PPO who claims they are not a PPO even though our insurance has them listed as a PPO. Each insists the other is wrong, and we keep getting an $800 bill. It's an "are not" ..."are too!" scenario in which we cannot participate but are financially obligated at the outcome. It's insane.

Can I please just hand my substantial monthly insurance payment over to a non-profit healthcare agency whose only objective is to keep me healthy, rather than giving it to healthcare gatekeepers whose only objective is to make it more difficult (financially and practically) for me to get medical care? It's like paying a daycare provider to neglect your child -- and having them demand increasing amounts of money to do it.

@kduhtoe: Great advice! PTs have helped me overcome physical issues that chiropractors failed miserably at.

Chiro isn't medicine and isn't scientific, and so it's not surprising that medical insurance would not want to pay for spurious tests and procedures ordered by a chiro "doctor". Why not try to get your health insurance to pay for astrology consults as well?

@drkev1976: Actually, the agreement is between the provider and the insurance. I visited a chiropractor's office whose paperwork said that they are not an involved party, and I called BS on them. They agreed.