L Sass
Cathlete
I know some of you are in the health insurance industry and I have a question. I am in the midst of a "discussion" soon to be appeal from the denial of a benefit. I took DS in for his 4-y.o. check up. One of the things the pediatrician performed is a hearing test (the calibrated test with the headphones and child raises hand when hearing a tone.)
My certificate of coverage says hearing tests are excluded except to the extent they are otherwise allowed elsewhere in the certificate. Under well child visits, allowed from birth to age 12, there is a specific INCLUSION for hearing tests as part of a well child visit at the frequency established by the Amer Academy of Pediatrics. At age 4 the AAP says a hearing test is recommended.
As you can guess my ins co denied coverage for the hearing test. I've been battling with them by phone for a month and will of course now file a written appeal. (Actually the first round of talks had the rep telling me that they made a mistake and the test should have been covered - she would resubmit. She also indicated that in her notes.) They have since denied the claim again, but THIS time when I called a different rep told me that yes, there is coverage, but ONLY when the hearing test is a whispered voice test or a tuning fork test. I asked where in my cert that was indicated and she said it was not in there - it was in the Ins Co accepted standards. I asked if the Doc would have have those standards, and she said no - it is an internal document (not even accessible on-line to docs). So I asked how the doc (or I) would know not to perform the standard in-office machine test, but rather one of these 2 "accepted" tests. She advised she had no way of knowing, but perhaps the doc's office should call the ins co prior to beginning every well child exam to see what would be covered.
So my question for you in that field is --- does that sound right to you? Does it make sense for these docs' offices to call prior to every patient seen to determine how to conduct a test or exam? Wouldn't they spend half their day on the phone? Please excuse my ignorance in this area. TIA
Lorrie
www.picturetrail.com/lsass
My certificate of coverage says hearing tests are excluded except to the extent they are otherwise allowed elsewhere in the certificate. Under well child visits, allowed from birth to age 12, there is a specific INCLUSION for hearing tests as part of a well child visit at the frequency established by the Amer Academy of Pediatrics. At age 4 the AAP says a hearing test is recommended.
As you can guess my ins co denied coverage for the hearing test. I've been battling with them by phone for a month and will of course now file a written appeal. (Actually the first round of talks had the rep telling me that they made a mistake and the test should have been covered - she would resubmit. She also indicated that in her notes.) They have since denied the claim again, but THIS time when I called a different rep told me that yes, there is coverage, but ONLY when the hearing test is a whispered voice test or a tuning fork test. I asked where in my cert that was indicated and she said it was not in there - it was in the Ins Co accepted standards. I asked if the Doc would have have those standards, and she said no - it is an internal document (not even accessible on-line to docs). So I asked how the doc (or I) would know not to perform the standard in-office machine test, but rather one of these 2 "accepted" tests. She advised she had no way of knowing, but perhaps the doc's office should call the ins co prior to beginning every well child exam to see what would be covered.
So my question for you in that field is --- does that sound right to you? Does it make sense for these docs' offices to call prior to every patient seen to determine how to conduct a test or exam? Wouldn't they spend half their day on the phone? Please excuse my ignorance in this area. TIA
Lorrie
www.picturetrail.com/lsass
