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Is this a Deception that Insurance Companies use to get around the ACA?
Old 04-18-2016, 01:05 PM   #1
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Is this a Deception that Insurance Companies use to get around the ACA?

I have a pacemaker and need a "Preventative" checkup every 6 months to make sure there is good battery life left.

Well the Insurance company says it is a Diagnostic Test Not a Preventative Maintenance test and therefore is billed as a "Specialist" Visit!

Well I looked up the Definition of a Pacemaker check and for the most part this is what it says.

"A pacemaker checkup is a safe procedure for patients with a heart disease. It is, in fact, a preventative measure used to make sure that there are no problems with the pacemaker and that the patient can live a normal, healthy life despite an existing heart problem."

I called the facility where I get it done and apparently the Insurance company does NOT have a preventative maintenance code for a Pacemaker checkup and classifies it as a Diagnostic which is billable.

Seems like they are circumventing the Law.
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Old 04-18-2016, 01:13 PM   #2
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The word "preventive" points to a specific series of services that are covered by the insurance premium. You can see the list here https://www.healthcare.gov/preventive-care-adults/ so it is not any care or service that is coded as preventive, only those on the list.
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Old 04-18-2016, 03:21 PM   #3
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Medical and legal terminology mean sometimes what the "experts" say they mean, not what they would mean to regular folk in conversation. Just how it is.
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Old 04-18-2016, 05:24 PM   #4
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Quote:
Originally Posted by ShokWaveRider View Post

Well the Insurance company says it is a Diagnostic Test Not a Preventative Maintenance test and therefore is billed as a "Specialist" Visit!
"A pacemaker checkup is a safe procedure for patients with a heart disease. It is, in fact, a preventative measure used to make sure that there are no problems with the pacemaker and that the patient can live a normal, healthy life despite an existing heart problem."

I called the facility where I get it done and apparently the Insurance company does NOT have a preventative maintenance code for a Pacemaker checkup and classifies it as a Diagnostic which is billable.
yeah, I do the same thing and have been charged this since 2014 (2013 I maxed out my OOP with getting the PM).
If they find something minor during a colonoscopy... then all future ones are diagnostic.... about half find something. My understanding the ACA drafters meant for the colonoscopy to be preventative even with previous findings.

maybe they'll get the PM check fixed. They could call my annual check up with the cardiologist preventative. Does much less checking than my GP during a physical. I always ask "when do I get the faster pacemaker?"
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Old 04-19-2016, 04:01 PM   #5
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I had a high deductible HSA plan for several years pre-ACA that provided free preventative checkups and I'm fairly certain that your condition would not have been considered 'preventative' pre-ACA either.
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Old 04-19-2016, 04:25 PM   #6
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I had a high deductible HSA plan for several years pre-ACA that provided free preventative checkups and I'm fairly certain that your condition would not have been considered 'preventative' pre-ACA either.
What kine of "preventative" procedures? Was a pacemaker check considered preventative?

Mine has not been considered preventative since I've had it... that is by the insurance companies.
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Old 04-19-2016, 08:17 PM   #7
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What kine of "preventative" procedures? Was a pacemaker check considered preventative?

Mine has not been considered preventative since I've had it... that is by the insurance companies.
My understanding is that any examination for a pre-existing condition is not considered preventative. All I got was the annual physical, standard blood work and vaccinations.
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Old 04-20-2016, 06:41 AM   #8
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Quote:
Originally Posted by bingybear View Post
If they find something minor during a colonoscopy... then all future ones are diagnostic.... about half find something. My understanding the ACA drafters meant for the colonoscopy to be preventative even with previous findings.
Quote:
Originally Posted by zinger1457 View Post
My understanding is that any examination for a pre-existing condition is not considered preventative.
My insurer instructs medical billers to code the colonoscopy as preventive (screening) when there is a personal history of polyps but no symptoms such as bleeding. Of course, the biller sometimes doesn't do this and has to submit a corrected claim.

Quote:
Refer the patient with no GI symptoms for a screening colonoscopy for these reasons:

Patient is age 50 with no high-risk factors
Patient has a personal history of colon cancer or colon polyps
Patient has a family history (first-degree relative) of colon cancer or colon polyps

Refer the patient for a diagnostic colonoscopy because of these symptoms:

Blood in stool/hemopositive stool
Bleeding from rectum
Iron deficiency anemia of unknown cause
Change in bowel habits
Persistent abdominal pain

A screening colonoscopy is a covered benefit. There is no cost share for members who have a preventive benefit plan.
Reference: 2014 Provider News | BlueCross BlueShield of South Carolina
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