sharonmich
New
In March 2022 I went to the ER because I thought I had a blood clot in my thigh. I did and I also had a pulmonary embolism. I was kept overnight in Observation and for a second night. I was admitted and discharged by the Hospitalist. On the second day, an Interventional Radiologist came into my room to tell me that although the clot was extensive and covered the total leg; it was decided that the clot would not be physically removed because the blood thinners were working well enough. That same day another Physician came to see me and explained that she was a Hematologist/Oncologist and that she wanted me to make an appt. to see her about the results of the blood tests she was going to do. She billed me for CPT 99221 on March 23, 2022, and the Radiologist billed me for CPT 99221 on March 23, 2022. Neither one of these doctors should have used this code because it is reserved for the Hospitalist. The cost for the office visit of the Hematologist after insurance was $273.00. A month after that I received a bill from the Radiologist Group for $974.00. They were out-of-network. Lucky me. My insurance company, Aetna, denied the claim because they were out of network and because the CPT code was wrong. I appealed and they denied my appeal and told me that I was responsible for the entire amount and that I should call the provider and ask them to dismiss the charges or ask them to lower the cost. They said that their LPN and Auditors agreed with the Denial explanation: (9) You do not owe this amount. We consider payment for this service to be part of the payment for another service on the same day. They went on to say that for initial INPATIENT encounters by physicians other than the admitting physician should use initial INPATIENT consultation codes (99251-99255). I was never INPATIENT, I came in for Observation and was discharged from Observation. Aetna says that although the provider is out-of-network with my plan, the claim was considered under my in-network benefits because of the emergency room services.????????What? Then they go on to say that the Coding used is not an eligible service per my plan of benefits and that I am responsible for all amounts above what is eligible for coverage. Then they defined " Recognized Charge " as being the amount of an out-of-network provider's charge that is eligible for coverage. The " Recognized Charge " for this claim is zero. So I owe $974.00. I can't make a claim under the " No Surprises Act " because in Arizona the bill must exceed $1000.00. Lucky me.... $24.00 short of that. And for the record, the claim for the Hematologist was paid under my $3200.00 deductible amount. With the wrong code. My question is: Should I have to pay that much for a 15-minute consultation when I was not given the opportunity to choose an in-network Radiologist and the one who was chosen never clarified his name on the bill and I don't know who exactly he was. If Aetna denied the claim for incorrect coding then should I be made to pay for services with the wrong code? What should I do? Should I go to the second level of appeals? Aetna is not going to pay. I thought that is why we purchase insurance so that we are not subjected to gouging. I am not satisfied with doing nothing, but I am not sure what to do next. Any advice would help. Thanks, Sharon Michalski