Post # 1
Member
3697 posts
Sugar bee
Hope someone out there can help me:
Our insurance plan (through BCBS) covers office visits at 100% with a copay for prenatal appointments, and everything with the billing went fine for my first appointment with an OB.
However, I decided I would rather work with a midwife, and thought I had jumped through all the hoops to verify that she would also be covered. I was informed in writing that yes, she would be treated as an in-network provider.
However, I just recieved a larger-than-expected bill for visit #2, and when I followed up with BCBS I was told it was because they filed it as an “outpatient visit” rather than an “office visit.” Outpatient visits are covered at 80% after deductible, apparently.
Ugh. I am going to call my provider this morning to see if they can revise and resubmit the filing as an office visit. I’m wondering how rigid this terminology is and whether that will be possible? (FWIW I only saw the midwife and her nurse that day, we did not do any ultrasounds or anything with other parts of the clinic, so according to the definitions I’ve seen online of “office” vs. “outpatient” visit, I could certainly justify calling it an office visit. She does practice out of a large system-based clinic rather than a private office, though. Is that what makes the difference? Or is there flexibility there?
Post # 3
Member
3683 posts
Sugar bee
I’d imagine that she would be willing to re-submit for you with the correct procedure code for an office visit as a courtesy to you. And, yes, the terminology is very, very rigid in the insurance industry. At the very least, if it has to be submitted as an outpatient visit, they should be able to explain the difference to you.
Post # 4
Member
41 posts
Newbee
@KCKnd2: This exact thing happened to me when I had my NT scan. I called my insurance carrier to find out why my EOB stated that the visit was out of network, when it was at the same large hospital-affiliated practice that I had been going to all along. They told me that the visit was billed as an “outpatient hospital visit” rather than an “office visit.” All of my prior visits, including those with u/s, had been billed as “office visits.” So, I called the practice administrator and told her the situation, and within an hour she called me back and told me that it had been re-submitted with the correct code.
It seems to be a result of sloppy billing practices on the part of the provider, at least in my case. I suggest calling the practice administrator to see if you can get them to sort it out.
Post # 5
Member
3697 posts
Sugar bee
@Rugelach: Thank you, this is what I plan to do as soon as my phone is charged! Fingers crossed that it will work out for me, too …
Post # 6
Member
9145 posts
Buzzing Beekeeper
- Wedding: November 2013 - St. Augustine Beach, FL
@KCKnd2: Ask the office if they can re-submit their claim as an office appointment. How is that an outpatient visit anyway? Most providers want to get paid so a discussion with the billing manager should work this out.
I used to do medical billing and not all billing clerks are properly trained on codes and sometimes the doctors/nurses themselves circle an uncovered procedure code (i.e. outpatient visit) when they really mean another covered code (i.e. office visit.) The faster you address this, the faster it can be corrected. Plus there is a limited amount of time the provider has to submit the claim with the proper code. So definitely call them today and get this straightened out.
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