When doctors recommend procedures that insurance companies don't cover, patients can find themselves trapped in an expensive, time-consuming ordeal that leaves them wondering who, if anyone, really has their best interests in mind. As consumers, their best option is usually persistent questioning of both groups, until they get a satisfactory answer.
I recently experienced the stress of such an experience when my insurance company, Aetna, denied coverage of my 20-week pregnancy ultrasound. That meant my doctor charged me for the full cost—$612. After recovering from the shock of receiving such a big bill, especially at a time when my husband and I are trying to save as much money as possible for baby-related costs, I called Aetna for an explanation. The customer service representative said that the sonogram my doctor's office billed for was considered "experimental." This explanation didn't make much sense to me, since 20-week ultrasounds are generally standard, and they're often the only one received throughout the entire pregnancy.
What happened next helps to illustrate why consumers—even insured ones like me—can so easily feel lost in our healthcare system. Each phone call to my doctor's office and my insurer seemed to underscore that the two did not agree on the type of procedure I should have received. That left me to cover the bill on my own. I'm certainly not the only one to find myself in this kind of situation. Across all types of medicine, some 10 to 15 percent of claims are denied. That creates a lot of headaches for patients who are already dealing with the stress of whatever health condition required the procedures in the first place.
In my case, I was able to use my reporting skills to investigate further. I called Aetna's corporate media office to ask about the company's coverage. Spokeswoman Wendy Morphew walked me through Aetna policies: The insurer does, in fact, cover 20-week ultrasounds, so there seemed to be some sort of "glitch" in the denial of my coverage. To me, this sounded like good news. I just needed to correct the glitch, and my problem would be solved.
It turned out not to be so easy. Upon further investigation, Morphew found that my doctor's office gives all of its patients a more complex ultrasound at the 20-week mark of pregnancy than the routine one Aetna covers, which is the reason I was denied coverage. It didn't seem as if it was entirely Aetna's fault: Even the nonprofit Society of Maternal-Fetal Medicine calls the more complex ultrasound unnecessary for most normal pregnancies, which mine was. So it seemed that my doctor was in error for recommending it.
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At my next appointment, I asked my doctor why she had ordered the complex ultrasound for me. She said it was the standard of care and the one she recommended for all her patients. She couldn't help me with the billing issue; that was my problem, but she could direct me toward the American College of Obstetricians and Gynecologists, which recommends the more complex ultrasound for everyone. In other words, two medical societies appeared to offer conflicting recommendations, and my doctor and Aetna subscribed to different philosophies.
Of course, not all procedures should be covered; some truly are unnecessary. The Wall Street Journal reports that as much as 30 percent of all healthcare spending goes toward tests and procedures that offer no medical value. Many health experts have pointed out that doctors often have a conflict of interest when it comes to recommending procedures that are performed in their offices, since scans and other technology-heavy measures tend to earn more money for their practices. How can a patient know what's best?
Aetna recommends that we take matters into our own hands. Joanne Armstrong, an obstetrician/gynecologist and head of women's health at Aetna, says patients should first look carefully at their own benefit plan to see what is covered and what is not. "As patients, we have to ask, 'What tests are we having?' " she says. A patient who is concerned about coverage of a specific procedure can get the insurance code that the doctor plans to use and ask the insurer if it is a covered procedure. (Of course, in emergencies, there's no time to do this kind of research.)
Then, if a patient is surprised to discover that a claim is later denied, Morphew recommends calling the insurer to check on the reason. The doctor could have submitted the wrong information or made a coding error, for example. If that doesn't resolve the problem, then she suggests following up with the doctor and possibly filing an appeal with the insurer with any relevant information from the doctor's office, including the reasoning for why the procedure was done. "If you think it's something that should be covered, you need to call, and not take 'No' for an answer, and keep going until you find out what the answer is," Morphew adds.
In the end, it seems to me that both Aetna and my doctor's office could have handled the situation better. When Aetna receives a claim for the more complex ultrasound, it could pay for it up to the amount of the routine ultrasound that it would have paid for in full. Otherwise, patients in my situation get no coverage, despite paying for it all these years. As for the doctor, she could have presented me with a choice between receiving the standard and the more complex ultrasound, so that I could decide for myself, instead of just billing me for the more expensive one.
Ultimately, I received a minor victory: After I asked my doctor's billing office for the discount that it normally provides to insurers, my bill went from $612 to $332—a savings of $280. On Morphew's recommendation, I filed an appeal with Aetna, but it was denied. Aetna's response said that after reviewing my medical records, it found that I received only a standard ultrasound and my doctor used the wrong code. (My doctor vigorously denies this and says that the more complex ultrasound was performed.) The next option is for me to initiate an external review of the situation through the state appeal office. According to America's Health Insurance Plans, which represents insurers, about 60 percent of appeals filed through states are upheld—in other words, the reviewers agree with the insurer. In 37 percent of the cases, they agree with the consumer.
Meanwhile, as my baby's due date approaches, I wonder what other hidden costs await us.