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I hate Health Insurance System and Doctors and Their Diagnosis Codes!!!!!!!!!!

Feb 24, 2011 - 8 comments

So..here I am ..17 weeks pregnant...it took us almost a year to get here...but we did it...that means we are not INFERTILE!!!!!!!!!!!!
This is how it all began....Me and my DH were trying since Jan 2010 and didn't get prego till August so decided to see our OBGYN so see if we have any problems or not...its logical that he is just going to test us to diagnose if we are infertile or not. Before going to the doctor we checked from our insurance company that only diagnosis is covered and not treatment and doctors ran all the blood tests and HSG-ray etc to diagnose whether we are infertile or not...he told us to iui...ivf (that is a treatment) but we decided to wait......he did not do any treatment on us to overcome infertility.....and now we are getting all kinds of bills saying we are infertile and our insurance compnay does not cover infertility treatments.....WHEN DID WE DO ANY TREATMENTS????????????????????????????????
Our doctor wrote all the diagnosis code related to infertility.....I spoke to my nurse and she said doc was treating you for infertility????????????? WHENNNNNNNNNNNNNN?????????????????
Why cant these people understand difference between diagnosis and treatment....I told my insurance company I am pregnant right now....naturally....how can I be infertile?????????????????
If you call insurance company they are saying to call your providers....providers does not understand that we are paying monthly health insurance for PPO so that everything is covered and why r we still getting all this bills....by not paying all those bills we are spoiling our credit history......what r we supposed to do????????????
Oh God please give them some common sense.......these doctors and insurance company are already earning so much and they are taking all our tax money and still asking for more???????????? Are you kidding me????????????
We are not that stupid...................doctor was treating you for infertility?????? REALLY........................****ERS!!!

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Avatar universal
by Kricket212, Feb 25, 2011
I am sorry you are getting these bills but let me say
INFERTILE is a BIG word to use when they are just checking to see why you were not getting pregnant.  There are many women in the world that have unexplained Infertility but not INFERTILE.
I have had all the tests done & they can't find anything wrong.  Does that make me INFERTILE?

I understand how upset you are.  I can tell you having an HSG is a normal test. They are just checking to see if your tubes are OPEN/Patent.  You need to get a copy of your records & find out if they are billing you for what they did.
There are specific names for these tests.  
You really need to find this out because if they are billing for somethig they didn't do that is insurance fraud/. (which I don't think is the case)  They may also be billing for a consult which is ALLOWED.

Again, I understand your frustration but can say you really hurt my feelings when I read your posting.  I hope you are able to get your insurance straightend out.

1396867 tn?1520810258
by hopeitworks, Feb 25, 2011
The diagnoses and treatment of infertililty or the underlying condition would be billed as infertility.
So if you went to the Dr with concerns about being infert or not being able to concieve and they ran test
in regards to that then the dx code would be infertility

However if your insurance company says they cover the diagnoses of infertility then they should over the lab

Its kinda a gray area there. In order to diagnoses you they have to run the tests. If you had a problem, and needed iui,ivf,art, etc then that is the "treatment"
Have you spoken to a supervisor at the insurance company???

Or has the dr office given you an itemized statement of the services with codes?

Avatar universal
by Amy1223, Feb 25, 2011
To hopeitworks......I did not speak to the supervisor of the insurance company as the rep said doctors have to change the codes and I dont think doctors are goign to change the code....once i hear somethign from doctors I will contact insurance company again. I checked those codes online and they are relateed to infertility....but just to check those symptoms...here nobody would understand indirect words.....their job is to deny all the claims with the word INFERTILITY so they will.....they wont listen to you or wont apply little bit of logic. Thanks for your comment.

Thanks....Kricket212 for your concern. I hope I get this clear out...I cried a lot yesterday and my DH was like think abt our baby and dont cry....my baby must be also stressed becoz of me....I said sorry to my baby...and made him/her understand how this idiotic world works!!!! Thanks!!!

1396867 tn?1520810258
by hopeitworks, Feb 25, 2011
Amy- I work for an insurance company thats why I was asking the questions about codes etc. Im sorry you are in this position. It is correct that the ins company can only process based on how the Dr billed. But what I dont understand in your case is your plan covers the "diagnoses" of infertility. How do they expect you to get diagnosed? Have the dr look at you at a office visit?!!
It makes no sense to me. I hope you can get this resolved. I understand the frustration you have.
I am often the middle person between dr office and our members.

Good Luck :)

and most of all CONGRATS!!! on your pregnancy!!!!

Avatar universal
by Amy1223, Feb 25, 2011
Thanks for your prompt reply. Doctor did not even touch me throughout my visit...he just ordered some blood tests + HSG
Progesterone + Blood drawing Fee...Dig code: 628.9 (unspecified Origin) and 628.0 (Associated with anovulation)...$64.84
Free T3, Free T4, TSH + Blood drawing Fee...Code 628.0....$142.39
Dehydroepiandrosterone, Estradiol, FSH-Pituitary, GlycoHB, LH, Prolactin, serum Code:628.9, 628.0, 256.4 (PCOS)...$341.07

I understand HSG-xray might not be covered fully...but blood tests??? blood drawing fees???
Insurance comp is behind those codes......what should I do??



1396867 tn?1520810258
by hopeitworks, Feb 25, 2011
all the codes you gave me are diagnosis codes

628.9 is famel infertility unspecified origin
628.0 is female infert associated with aovulation
256.4 is polysistic ovaries
These all go throu as medical diagnosis codes but related to infertility

The tests the dr ran sound like normal typical tests that would be ran to see if there is in fact a infertility factor
I dont think in your case your dr office did anything wrong

I think you need to call the insurance company and get clarifcation on your benefits.
What exactly is covered if they told you they cover the diagnosis
Most plans cover the diagnosis and treatment of the underlying condition when it comes to infertility
Well they have to run tests to determine if there is a underlyning cond. In your case there wasnt

I would start there get varification. Then if you have to appeal if with the insurance company.
Speak to a super if necc, adv you called prior and what you were quoted see if they can help

Avatar universal
by Amy1223, Feb 25, 2011
Thanks, I am waiting to hear from my doc....if they r not changing the code...which they wont...I will call insurance comp. again. Lets see how it goes....but its too much to handle sometimes....why cant doctors and Insur. comp work hand in hand.....why always we hv to suffer??
I will let you know how it goes. Thanks once again for ur help. I really appreciate it.

1396867 tn?1520810258
by hopeitworks, Feb 25, 2011
Alot of insurance companies now have specialists( im one for my company, also I have aetna and they have them)
that you can speak with if the agent/rep isnt anwering your questions or you feel like you need additional assistance. They will step in and speak to the Dr office if neccessary or get your plan reviewed etc. They have a bit more knowledge/training then the rep who answers the phone.

Im glad I could offer some advice. Im thankful everyday for getting a job with insurance. Because it is SO HARD to understand and know what ?s to ask. There is always some black hole that was skipped over or something comes up you have no control over. So I really do understand where you are coming from.

Feel free to message me anytime I dont mind putting my 2cents in if I can.
:)

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