Can medical procedures be reclassified for insurance purposes without the patient's knowledge?

Question

I went to a medical center for a screening procedure, which the insurance policy stipulated as being covered in full.  Based on the answers I gave to the physician after coming into the office (just before they performed the procedure), the center re-classified the procedure as "diagnostic" and now I am getting bills for $425 which they said that the insurance company won't cover. I wasn't told about any re-classification until after receiving the bill.  Is that legal/acceptable for them to do?

Anonymous · Accepted Answer

Coding the procedure as anything EXCEPT what it really is, is fraud. 

So, was it REALLY screening, or was it diagnostic?   Let me explain the difference - screening, is when  you reach a certain age, for example, and have NO symptoms, but get a mammogram, just because you're 45, and that's a recommended screening age.

If you have any SYMPTOMS, where something might be wrong, like a lump in your breast, then the mammogram is NOT a screening - it's a DIAGNOSTIC test.

So.  WHY did you have the test?  If it was to "rule out" something, or because you or the doctor thought something MIGHT be wrong, or something WAS wrong and you want to make sure it got fixed, then yes, it's diagnostic.

StephenWeinstein · Answer

It is not their option or your option.  They must tell the truth.  If the reason for the procedure was diagnostic, then they must classify it that way.  It would not be legal or acceptable for them to classify it as screening if it was diagnostic.

"Can" is the wrong word.  The correct word is "must".

Anonymous · Answer

happens all the time.  get the medical records and send them to the insurance company yourself.  keep a copy for your records.

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Can medical procedures be reclassified for insurance purposes without the patient's knowledge?

3 Answers