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BCBS tells patient "all they need to do is bill as routine"

  1. #1
    Unhappy BCBS tells patient "all they need to do is bill as routine"
    Clearnace Sale
    This is so irritating! A 3 year old patient has a panel of lab work drawn because her mother stated that she was having excessive thirst. She wanted us to test her daughter for juvenial diabetes. We billed the lab work out as polydipsia. The mother is upset because these labs were applied to her deductible because they were not billed as routine and that, according to BCBS, all we have to do is rebill it as routine and they will cover it 100%. Well, the labs were not routine as she was symtomatic. She proceeded to say that BCBS compared this to a pregnancy test. If a patient has a pregnancy test drawn and it comes back negative then it can be billed as routine because the thing that was tested for was not found. Since all of her daughter's labs came back normal so juvenial diabetes was not found.

    Now I am utterly confused....Can I change the diagnosis on these labs?? It doesn't seem to be that a panel testing for juvenial diabetes would ever be considered routine.

  2. #2
    No you can not change this. This is a benefit issue, not a coding issue.

    If you do a pregnancy test you have a reason, you don't wait for the results to bill, what are they talking about? You have a missed period, you have unprotected sex, you have contraception management, etc. The point is the dx doesn't change after the fact on a pregnancy test either regardless of the outcome.

    Insurance companies are really good at placing blame on providers. Sure they will pay for it if we code it different, they just fail to mention to the patient this is fraud on the providers part and all the fun stuff that happens to those who commit fraud.

    Good luck, your not alone!

    Laura, CPC, CEMC

  3. #3
    Yes I hate when this happens. I get calls back all the time. I tell the patient unless they came in to routinely have it done then it should not be changed. If you are complaining of something then how could this be routine?
    Herbie W Lorona Jr., CPC, CPC-H

  4. #4
    You are right on Laura!!!!
    Herbie W Lorona Jr., CPC, CPC-H

  5. #5
    I am so glad that I am not going crazy about thinking that it cannot be changed. The patient is going to call me back because she is not happy with my previous replies and I got all confused and told her I could do some further checking. UGH...I am not looking forward to this call back.

  6. #6
    Greeley, Colorado
    I would let the mother know that what the insurance suggested and what she is asking for is fraud. You can also quote her the ICD-9 coding guidelines that state "The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening. In these cases, the sign or symptom is used to explain the reason for the test."

    These situations really irritate me!
    Good luck!
    Lisa Bledsoe, CPC, CPMA

  7. #7
    Good idea Lisa,

    Make sure you point that out to the patient. I will start using that as well. Never though about that one!
    Herbie W Lorona Jr., CPC, CPC-H

  8. #8
    That is a great excerpt to reference to! Thanks! Now I will brace for the phone call. I have put an email in to our BCBS rep as well to ask her why the BCBS operators continue to tell patients incorrect information.

  9. #9
    Greeley, Colorado
    Good luck with that one! Every insurance seems to do the same thing..."if your doctor had coded it as routine/screening/preventive it would be covered". Well, if it was routine/screening/preventive we would have coded it that way to begin with!
    Lisa Bledsoe, CPC, CPMA

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