Insurance Rant

[moonpies4misfits]

I'm so mad right now. I had a doctors visit back in August that my insurance is refusing to cover. It was a standard follow-up with my PCP where we also happened to also talk about weight loss options. No treatment, no prescriptions, we just discussed possible options.

Well, as it turns out, simply getting diagnosed with obesity means my visit is not covered. The exact wording I was given was "the claim was billed with a diagnosis that is specifically excluded from the plan." I am freaking livid. I pay for the highest tier of insurance my company offers. I'm paying extra money for "better" coverage but I'm not allowed to simply talk about being fat with my doctor without having to pay out of pocket?

Needless to say, I will be asking my doctors office to rebill the insurance company.

Edit to add: These are the codes that my insurance company referenced when they said my visit was not covered.

• 99214: Established patient office or other outpatient visit, 30-39 minutes.
• E66.9 Obesity, unspecified

There are other diagnoses that were listed, but none of them were new. They also ran a number of blood tests that they have run before.

ETA 2.0: Confirmed that the CPT code is one that has been used before without issue, so this really is falling all on the obesity code being used.

 

[brentm]

They'd rather pay for more extreme and expensive corrective procedures than pay for prevention.

/s

 

[raw_oyster_eater]

they should pay for a followup. Put in an appeal thru the insurance.

 

[moonpies4misfits]

they should pay for a followup. Put in an appeal thru the insurance.

They normally do, but because the diagnosis code for obesity was added to the visit they are not covering it. I have an appointment tomorrow and I will ask them to rebill the insurance so it should be settled. I shouldn't have to jump through hoops though.

 

[Jailbreak7]

They normally do, but because the diagnosis code for obesity was added to the visit they are not covering it. I have an appointment tomorrow and I will ask them to rebill the insurance so it should be settled. I shouldn't have to jump through hoops though.

you should tamper your expectations... providers do not rebill by changing diag codes because insurance did not pay for the visit.. you may get lucky, but I would put chances at 0.1%

having said that, the whole situation is just ridiculous.. you talked about your health...

 

[raw_oyster_eater]

They normally do, but because the diagnosis code for obesity was added to the visit they are not covering it. I have an appointment tomorrow and I will ask them to rebill the insurance so it should be settled. I shouldn't have to jump through hoops though.

again: It was a standard follow-up with my PCP

you are buying into their bullshit explanation. i took my ins to small claims and won on a colonoscopy. they don't want to pay for anesthesia, they don't want to pay because they found a polyp. enough people appeal and its not worth it and they'll stop.

periodically they start inventing new excuses to deny but once people start pushing back they'll stop it.


scumbags they are. worst scumbags on earth even counting used car salesmen. they're like scammers.

 

[moonpies4misfits]

you should tamper your expectations... providers do not rebill by changing diag codes because insurance did not pay for the visit.. you may get lucky, but I would put chances at 0.1%

having said that, the whole situation is just ridiculous.. you talked about your health...

I've had it done before.

 

[Vacation4us]

I can’t imagine not paying for a doctor’s visit discussing your health. Geez.
Good luck

 

[nonyabizznez]

I'm so mad right now. I had a doctors visit back in August that my insurance is refusing to cover. It was a standard follow-up with my PCP where we also happened to also talk about weight loss options. No treatment, no prescriptions, we just discussed possible options.

Well, as it turns out, simply getting diagnosed with obesity means my visit is not covered. The exact wording I was given was "the claim was billed with a diagnosis that is specifically excluded from the plan." I am freaking livid. I pay for the highest tier of insurance my company offers. I'm paying extra money for "better" coverage but I'm not allowed to simply talk about being fat with my doctor without having to pay out of pocket?

Needless to say, I will be asking my doctors office to rebill the insurance company.

Perhaps have them re-bill it as a "wellness" visit... This gets by without even a copay with mine (Medicare Advantage). My PCP has me book this this way with a wink... She also got Mounjaro approved through Medicare! My Superhero! (Until she takes it away for being to skinny next time she sees me)

 

[MiniatureSnail]

They did something wrong...Do you know which ICD-10 and CPT codes they used?

Editing to add: I know we shit on Reddit around here, but these subs might be helpful. I've gotten a couple of questions answered there that I couldn't figure out myself before (I worked in billing but in a very narrow scope).

https://www.reddit.com/r/CodingandBilling/

https://www.reddit.com/r/MedicalCoding/

 

[moonpies4misfits]

They did something wrong...Do you know which ICD-10 and CPT codes they used?

Editing to add: I know we shit on Reddit around here, but these subs might be helpful. I've gotten a couple of questions answered there that I couldn't figure out myself before (I worked in billing but in a very narrow scope).

https://www.reddit.com/r/CodingandBilling/

https://www.reddit.com/r/MedicalCoding/

99214: Established patient office or other outpatient visit, 30-39 minutes.
E66.9 Obesity, unspecified

I also had a number of blood tests done.

Edit to add: There are a number of other diagnoses on that visit, none of which were new. The above is just what the insurance company said is the specific reason as to why I was denied and they told me "obesity care isn't covered by your plan."

 

[moonpies4misfits]

you are buying into their bullshit explanation.

I never said I bought it and I never said their explanation wasn't bullshit. My frustration is with the fact that I have to fight them AT ALL

 

[MiniatureSnail]

99214: Established patient office or other outpatient visit, 30-39 minutes.
E66.9 Obesity, unspecified

I also had a number of blood tests done.

Edit to add: There are a number of other diagnoses on that visit, none of which were new. The above is just what the insurance company said is the specific reason as to why I was denied and they told me "obesity care isn't covered by your plan."

That is...crazy. Please ask the coding reddits. Something is wrong here, but I don't know enough about Primary Care codes to help you. Like, maybe that code needs to be bundled with something else to be accepted (like a BMI code--I'm just guessing here)? ICD codes aren't necessarily what you're being treated for, they're also just supposed to describe what's wrong with you. You could have lots and lots of diagnosis codes for every visit. Does this mean if your MD doesn't remove the E66.9 from every subsequent visit that they will all be denied, as well? That's bonkers.

Maybe try calling insurance back and see if you get a different person who knows more? I'm sorry this is happening, that's SO frustrating.

 

[moonpies4misfits]

Does this mean if your MD doesn't remove the E66.9 from every subsequent visit that they will all be denied, as well? That's bonkers.

I asked this as well and I'm waiting on a response.

Maybe try calling insurance back and see if you get a different person who knows more? I'm sorry this is happening, that's SO frustrating.

I've called them twice and I even got the payroll and benefits manager involved.

 

[moonpies4misfits]

Update for anyone following along: I dug through my medical records and I have multiple office visits that were billed with code 99214 that were covered.

I just called my insurance again to confirm it was simply because code E66.9 (Obesity, unspecified) was added to my list of diagnoses. This is 100% because of a massive issue with my insurance policy. My doctors office did not screw up the billing, as the only thing that changed between this visit and other visits that were covered by insurance was the addition of code E66.9.

 

[yelloeyes]

Perhaps have them re-bill it as a "wellness" visit... This gets by without even a copay with mine (Medicare Advantage). My PCP has me book this this way with a wink... She also got Mounjaro approved through Medicare! My Superhero! (Until she takes it away for being to skinny next time she sees me)

Can I ask how much you pay through medicare and what supplemental you have? I have a friend whose husband was prescribed Ozempic but it will cost them $700/mo. Thanks.

 

[nonyabizznez]

Can I ask how much you pay through medicare and what supplemental you have? I have a friend whose husband was prescribed Ozempic but it will cost them $700/mo. Thanks.

Well here's where I had a similar issue as @moonpies4misfits. My doctor kept including the word (code?) "obesity" with a diabetes diagnosis and it was denied repeatedly (I think 4 times in 2wks). The only way Ozempic or Mounjaro are covered (2024) is with a "clean" diabetes diagnosis... No other tags like obesity or sleep apnea etc... ANY medication with the word obesity is not covered in Medicare, it's actually against the law! I have Humana's Advantage plan with drug coverage. I have found them to be really excellent.

Out of pocket is somewhat complicated (see pic) but I think it's the same for all Medicare plans. Basically you have a small copay the first few months ($47 was mine) while getting full price of the drug credited to your deductable (so the first 4 fills get you to Stage 2 coverage gap or "donut hole" ) then you pay 25% (about $257/mo). In a perfect world after Stage 2 your be getting free fills at the end of the plan year. Unfortunately with shortages and ordering/acquisition delays they've got my last refill timed for the last week of the year... Your refill eligibility date is based on the last fill so if it was two weeks late you don't get to make it up.

Next year will be different (apparently less) but In 2024 factoring in the stages I've paid an average $170/mo or so out of pocket. This is for Mounjaro.