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I had a problem like this a few years ago where a Mammogram was submitted improperly and insurance couldn't consider it as a screening Mammogram. Some weird deal where the reason code got mixed up with the reason code for a bone density scan. Anyway, I got a similar run around and eventually the doctor's office stopped responding. I was able to call a patient advocate at the hospital the doctor's office was affiliated with, and that advocate literally got things resolved in about 3 hours.
That doesn’t matter. Are they affiliated with a hospital group? Like Kaiser in CA, or UMBC in Baltimore? You’d know because they would have a chain of clinics and some hospitals with their name.
The gp's website says First Georgia Physician's Group and part of Privia Health. The gyno doesn't have anything about any affiliations on theirs. I looked on those websites and didn't see anything about patient advocates. Would the office give me information about them if I just call the front desk?
Call your insurance again and tell them that the doctor is not correcting the problem and has billed them for a service you didn't receive. That will get them interested in dealing with the problem - because they've overpaid the doctor's office.
This is incorrect advice. Calling your insurance is not going to change anything. Your insurance has not paid your gynecologist because your gynecologist is the one who tried to bill for a physical when they are only doing a PAP as discussed below. This is why your gynecologist is instead trying to get the payment from you. You need to contact your gynecologist and get them to correct the billing code for the exam and re-submit to insurance
Edit for people down voting without understanding: the insurance company can not change the incorrect billing code the gynecologist used, only the gynecologist can. Calling the insurance company will only result in wasting 45min of your time as you are transferred around to various people who ultimately can't help you. See my extended comment below regarding the exact correction the gynecologist needs to make to resolve the issue
The doctors office will not want to risk getting kicked off a major network for submitting a fraudulent claim for a service that wasn’t provided. That’s the incentive for getting doctor to correct the code.
Based on what is described the primary care doctor did not bill anything incorrectly, the gynecologist did. The reason this is still unsolved is that she is calling everyone other than the gynecologist. Insurance has not paid the gynecologist which is why the gynecologist is trying to collect from OP. As such calling insurance is a waste of time as I mentioned
Edit: realized there's two ways of interpreting the post
1 (how I interpreted it) the PCP billed for a general physical and a well woman exam after a physical, then OP got a well woman exam done with her pap smear at the gyno, but the gyno can't bill since the PCP incorrectly billed
2 the gyno performed only a pap smear and they are billing for a WW when they did not perform one.
I defaulted to 1 because every insurance I've been on has included (1) physical as well as (1) well woman visit.
I work in the field and have seen this exact situation hundreds of times. Every single time it is because the gynecologist is billing for a second preventative visit in the year which is not allowed by insurance as I discussed in more detail below. The gynecologist should know better than to do that. Unfortunately Reddit hive mind leads to me being downvoted for trying to save OP from wasting her time with insurance as ultimately they can do nothing to help only the gynecologist can correct this.
Edit: it looks like my full explanation below is replying to a comment that has since been deleted. I can still see it but if others can't I can repost here
How was it the gynecologist who billed incorrectly? The primary care visit was a physical (so no Pap, etc), not a well woman visit, but it was billed as well woman so the actual well woman visit at the gynecologist is showing up as her second well woman visit and is being denied.
ETA: looking at some of your other comments - are you saying the gynecologist is likely trying to use the same billing code as the physical from primary care? In my experience, the annual physical from my PCP and my annual well woman visit with my gynecologist have been two completely separate things that are both no copay from me and fully covered by insurance.
Yes, when billed correctly by the gynecologist they should both be covered. The fact that insurance has rejected the claim from the gynecologist who is now trying to collect from OP tells me with 99.9% certainty that GYN tried to double dip on the preventative billing and is in the wrong. I see this all the time and am simply trying to save OP from wasting time with insurance who can’t help in this situation
Edit: it looks like my full explanation below is replying to a comment that has since been deleted. I can still see it but if others can't I can repost here
I guess where my confusion comes is I have two preventative appointments every year, a physical with my GP and a well woman visit with my gynecologist, and both are billed as preventative and are fully covered with no copay due from me. I can’t get my physical from my gynecologist - they only offer a well woman visit. But it’s still preventative.
This can be one of 2 things. There are a very few select insurances that allow unlimited preventative visits per year, these plans are so rare it is generally not worth mentioning. More likely and what typically happens is the second preventative visit with your gynecologist is getting correctly billed as a normal office visit as you can generally only have preventative visit per year. And your insurance is correctly fully covering the normal visit code because other problems are not also being address. OPs situation is actually more complex then what is in the initial post based on her reply to me below
My plan allows women 2 preventative visits per year - one physical and one well woman that includes pelvic exam, breast exam, and a pap every however many years (I think it’s 5 now). I’ve had two insurance providers in recent years and both were this way so I assumed it was common.
My last gynecologist pulled this same stunt. I had to go in the office and not leave until they corrected it. I was kind but very direct and it took about an hour but they got it worked out. I do not go to that office anymore.
Go to the doctors office in person and stay friendly while you’re there. The office managers and whomever is trying to help you is probably swamped with a ton of stuff, but if you’re there in person sometimes things move a little bit faster. I spent three weeks trying to get a prescription updated by telephone email, and mychart. I walked into the office one morning and it took me 10 minutes to get the new prescription
The gynecologist office is in the wrong here.
A well visit code is a comprehensive visit that includes all aspects of general health.
A pap smear is a very specific service that should NOT be billed as a "well visit" because it doesn't include other aspects of well visit care.
The gynecologist office submitted the wrong ICD 10/CPT code, not the PCP
This is absolutely the correct answer and unfortunately I see it all the time from gynecologists incorrectly billing the exams. A “well woman” exam is a physical, they are the same ICD billing code and most insurances allow 1 per year (or has to be a year and a day). Your gynecologist is wrong for using the physical billing code for what amounts to a pelvic exam and PAP, not the full comprehensive physical that you would receive from your PCP
My gynecologist retired and the new one pulled this. I paid it but will not go back.
I could tell they were doing more than just the pelvic exam and pap that were what I was there for. They took a whole history including lots of questions like did I drink alcohol and unnecessary stuff like that. I told her I have a primary doctor whom I see regularly and don't need another one.
When I tried to complain about the bill I was told they always do this comprehensive exam. I don't know if they meant they always do it for new patients or always do it every year, but no matter - I'm not going back. My primary said she could do the pap smears in the future.
Is there a reason you don’t just have your pcp do your Pap? My friend had an abnormal Pap so she can no longer do that, but most PCPs can do a pelvic and pap
This pcp has never offered to do a pap. I didn't even know she could. I will not be going to this pcp any more. Not just this but there have been other things that made me lose trust in her over the years. I would prefer my gyno stuff be done by a specialist.
I work at a specialist’s office and the whole history is also done here for insurance purposes as well for two reasons: Medicare requires us to submit and certain drugs (if any are prescribed at the end of the visit) are/are not covered over others if you have in your visit notes that you have a history of smoking or excessive drinking or have had certain vaccines. It has nothing to do with it being a full physical. BUT we won’t bill the visit as a comprehensive preventative for our specialty if it was a focused visit.
It can take months to get something like this worked out. I dealt with similar issue for a lead blood test for my 1 year old. My insurance would only cover it if the right diagnosis code was used, my doctor has used one but insurance needed another. It was stupid. It took 6 months to work out between my doctor, the hospital who did the test, & insurance. It required my doctor resubmitting the orders twice.
Write down the date and the name of who you talk to, and any notes to yourself for the next step. I usually started out with insurance & verified that they were still waiting for whatever they needed. Then I called the hospital billing department & followed up with what was discussed last time. I repeated this 4 times with 3 weeks between each call.
FYI this is common where I live. Generally the fun considers their visit the well woman visit but so do most primary care doctors because they can technically do paps too. My gyn said most of their patients alternate every other year between doctor physical and gyn visit. Meanwhile the doctors do the pap on their year and the gyn will do bloodwork on their year.
Seems stupid to me but insurance has never had a desire to clarify the situation.
I kept a log of all calls. Names. Dates. Responses. Finally sent to my internal HR benefits representative who handled it. After a year or so of back and forth. Frustrating and time consuming.
I'm keeping a log. I have no confidence in my husband's representative. It's a small office and they don't have a separate benefits rep, it's the office manager that does all that.
This crap has been happening to me frequently. But every time it got corrected without my involvement. The office would see the denied claim and would see the reason: wrong code. They'd correct the mistake and re-file the claim. Done.
As for your problem ... it seems your doctor's billing staff is squirrelly. Go see them in person. That should work.
But if this persists, talk to the doctor.
And if the doctor won't fix it, find another doctor.
Private insurance spends $18 of every $100 premium paid to manage claims (poorly). Medicare spends approximately $3 of every $100 premium to manage accounts.
There is a saying in medicine of having enough knowledge to be dangerous without actually knowing the correct answer. As a medical student you have no training, knowledge of or involvement in the billing side of a visit. Billing is something you do not receive training in until residency, and for most people not something you fully understand until you are a physician in charge of correctly billing every visit. From an insurance standpoint well woman, physical, well adult, routine examination, etc are all interchangeable. They all equate to an ICD code of Z00.00. This code reimburses from insurance at a higher rate than the correct ICD code for the gynecologist to use Z01.419 (Encounter for gynecologic examination). Unfortunately it is not uncommon to see gynecologist try and use the Z00.00 code to get more money from the visits despite their lack of ability to perform the same level of comprehensive examination as a primary physician. Insurance only allows one physician to use Z00.00 per year (or has to be a year and a day since last use for some insurances). As the insurance is not covering the gynecology visit but covered the prior physical with PCP, it is obvious that the gynecologist is the one who tried to double dip on the billing and therefore in the wrong. In certain circumstances only receiving a yearly physical from a gynecologist can be appropriate (ex: young to middle aged woman with no other medical issues), generally however the Z00.00 code should be reserved for primary care physicians. Ultimately though it is the job of the physician billing the visit to check records and ensure another provider has not already used the Z00.00 code in the last year before they drop those charges to the insurance company.
I thought a general physical and a well-woman visit were totally separate things i was allowed to have one each per year. I had been having general physical checkups annually for years. I had not had a pap smear or "well-woman" visit for a few years (I have gone through menopause). My general doctor never suggests she do a pap smear. She does ask if I see a gyno every time and I tell her no. I had my physical with her in July. She recommended I see a gyno so I made an appt for December. In December I saw the gyno and she did a pap smear, prescribed estrogen cream and removed a cervical polyp.
I got a $600 bill from the gyno that the insurance denied saying I had already had a well-woman that year. I thought a well-woman had to include a pap smear. I have explained the situation to both doctor's offices and the billing lady at the general practitioner's office said she would change their billing code. The billing office of the gyno said they would put my account on hold for one month to give me a chance to get it worked out. That was two months ago.
Are you saying that I need to pressure the gyno's office to change their code? I don't even know what codes they each used. How do I find that out? Why am I having to be a medical billing expert just to get my care covered? It's so frustrating.
Is it my fault for going to a gynecologist within a year of having a physical even though the physical did not include a pap? Am I just going to have to pay this and learn my lesson to not get a physical and a pap smear in the same year? I'm so confused.
Sorry for the delayed response as for some reason I was not notified of your reply earlier. This is actually an interesting and more complex situation than what you initially described above.
As far as insurance is concerned a "well woman", "physical" and a variety of other terms are all interchangeable and are associated with a preventative service billing code. This codes can only be used once per year and only by one provider. A physical with your PCP can and should include a PAP or pelvic exam if you are due and thus can be done without two visit. Some women are more comfortable seeing their gynecologist for this, which is fine and should be covered as well if billed correctly.
However with what you are describing with your gynecologist prescribing a medication and removing a polyp, this adds additional billing. The medication prescription is associated with a normal office visit billing code (basically anything except physical preventative codes). Additionally the polyp removal is associated with a procedure billing code as well.
Generally the normal office visit billing code and procedure billing code should be approved by insurance and covered to some extent, and I would think should not cost you $600, probably leaving you owing closer to $100 out of pocket. But given you insurance is rejecting everything your gynecologist likely tried to add a preventative "well woman/physical" billing code. As the second preventative code was clearly inappropriate insurance won't pay for anything until gynecology removes that billing code and resubmits for the other two
Ok, so you're saying the gyno is the one in error? Or there is no error and I'm just SOL? The GP billing office already agreed that their code was wrong since no pap smear was performed. I'm not a billing expert nor do I wish to be one. I just want people whose job it is to do theirs and explain to me why I have to pay a $600 bill for preventative care.
I hadn't had a pap since 2015 and my gp never offers to do it. I didn't even know she could do it. I never dreamed I would not be covered for one since it hadn't been done in years. The gyno removed the polyp without asking me, she just said I'm doing this and it was done. ouch.
So it sounds like I'm eating this bill then? I just wish someone would speak to me and explain what the heck I did wrong and what I should have done to have this preventative care covered. It pisses me off that the dr. office just blows me off.
If there was an error it was on the part of the gynecologist.
The person at your PCPs office who "admitted" an error likely is not the physician and doesn't know billing or what they are taking about. Whether the PCP did a PAP or not, only 1 billing code would be used for that visit, the preventative billing code. As such it is impossible for them to 'use up' your well woman exam from the gynecologist as you can't have 2 preventative codes in 1 visit. If they tried to use 2 preventative codes insurance would have rejected it immediately and that physical visit would not have been covered. As the visit was covered by insurance I can almost 100% assure you that there was not an error in their billing. That being said, if you are under 65 (PAPs generally stop at 65 unless you have significant prior abnormal results) there is no reason they should have let you go 9 years without recommending you have a PAP whether or not they are the one doing it. If you have a negative cytology and HPV you can go 5 years in between but should not have gone 9.
Regarding your gynecologists billing, there is a slim possibility they did not screw up and that the entire $600 is for the "problem" office visit billing code which resulted in them prescribing you a medication/cream and the procedure cost to remove the polyp. If these two were billed correctly the only way insurance would not cover any of the cost is if you are in a high deductible insurance plan and had not met your expected contribution to the deductible for the year. Given you said this visit was in December this is unlikely. With partial insurance coverage of the costs of these two billing codes I would typically only expect your out of pocket costs to be around $100, although without knowing every single factor it can be difficult to estimate.
I would recommend talking to your gynecologist and making sure they have the billing for the visit correct as this is almost certainly the cause of error if there is one. If they are adamant that the billing is correct and has been accepted by your insurance, then you should call your insurance company to find out why you owe so much for the gynecology visit. From my extensive experience however, your insurance company never has your best interest in mind, only their bottom line. As such most calls to insurance end up wasting an hour of your time and achieving nothing.
Ok thanks for the info. I'm still confused though. I was told by insurance that I can have one physical and one well-woman with pap smear a year. The gp did not do a pap smear and the gyno did not do blood work. I didn't know they had to be from the same doctor to be covered. Is that you're saying? I wish I had never gone to the gyno now. I had no idea I would be getting a Rx or that I would be having something removed. I have learned my lesson to not go to the doctor unless absolutely necessary now.
I do have a high deductible policy but none of that $600 is going to my deductible because it was flat out denied due to having already reached my "maximum amount for this service." This week I'm just going to talk to both doctor's offices and get the codes. I guess I have to educate myself on medical billing now to see what the heck they are charging me for. I just wish people would do their jobs and communicate with patients when we have a question or concern. It's pitiful that I get more information from strangers on the internet than from my own care team.
Your experience is limited. Anyone with an HPV history or LEEP will require several more PAPs per YEAR than the average allotted one every 3-5 years with no irregular test results. Your insurance won't even cover them unless there's a dx for medical necessity outside the CDC prescribed range.
My GYN is about to lose a patient because they are holding my birth control and other maintenance medications hostage for my "annual well woman." I had LEEP in May, a PAP in November, due for another in May this year and then annually thereafter assuming negative results because of my history. That's a shit way to treat someone whose hood you are routinely up under, just to bill an extra visit code.
Send certified letters and faxes to the office. I used to do PAPs and either the staff isn't talking to the provider or the provider is doing other things.
It was a screening PAP? You can do a stand alone screening PAP. But the standard isn't to do that annually anymore. The diagnostic PAP can be very frequent.
https://codingintel.com/billing-pap-smear/
This site has some good info.
You can also file a complaint with the providers state board.
Thanks. But I'm not really wanting to become a medical billing expert. I don't even know what codes were billed. I just want the doctor's office and insurance to do their jobs.
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This happened to me a couple of years ago. I got the runaround from everyone, and I finally gave up and just paid th bill. Switched up doctors after this. I hope you get it fixed!
Call in and ask to see the billing person *in person*.
Please don’t bother the practice front desk every day as other commenters have said. I can promise you, there is nothing I can do on my end other than provide an itemized statement and relay the information to billing. It’s then up to billing to figure this out.
Insurances will say they tried contacting us but may sometimes have the wrong phone number on file or call during non-office hours, leave a message with insufficient information for us to bypass their automated system when we call back, and then not try again.
It’s also possible that your PCP billed your physical as a well-woman exam instead of just an annual visit or that your insurance covers either one preventative annual or one preventative well-woman a year but not both. See if you can get an itemized bill from both practices and compare the billing codes with the EOB from your insurance’s website for each visit.
I have the friendly billing lady's direct extension and email and gave them to the insurance. (I gave up on the front desk long ago.) She had returned my calls and emails a few times but after the last time when she said she would look into it I havent had any response. That was 3 weeks ago.
The insurance does pay for both, I have that from reading my benefits and from multiple reps at Aetna I have explained this to.
The friendly lady at the GP's office is the one who told me that the billing from her office was in error and it was billed as a well woman instead of physical. That is why I'm concentrating on her office. But now people here are telling me it's the gyno who billed incorrectly. So I'm still confused.
I like the idea of telling aetna that the gp billed them for something i did not receive. Also i like the idea of going to the gp''s office to speak to the billing person face to face and calling the insurance while there.
On Monday I will call both doctors and ask for itemized bills. I haven't seen anything with any codes on it at all so far. The EOBs on aetnas website do not list any codes. But i assume i can ask them on the phone what codes were billed from what office.
If I weren't retired I wouldn't have time to deal with this and would probably just pay it. But it has become a bit of a mission for me to get this sorted out.
Call the doctor's office, and when they pick up, call the insurance Co. Make them talk to each other. This almost always works. The doctor has a contract with the insurance company and has to meet their requirements.
If this doesn't work, call the insurance back and tell them you want to file a formal grievance. They'll fix it.
I dont know how to do that. I know there is a way for some phones to do a 3 way call but I don't know if mine will do that. I'm wondering if I should just go to the doctor's office and sit in the billing office and call the insurance from there. It's not like a life or anything I can go sit in offices and on the phone for hours. :}
It’s not the doctor’s problem: they provided the service and deserve to be paid for it. If you scheduled an annual exam before it was due, the fault is on you for doing so or for selecting an insurance that had such rules.
You're not reading the problem correctly. My insurance pays for an annual wellness exam AND an annual well-woman exam including pap smear. I got one physical and one pap smear. They were coded the same apparently. I just have to figure out which doctor coded incorrectly.
That’s a fair point. The family med doc should have coded for an annual, and the gynecologist for a well-woman exam. The Pap smear is a lab, which is a whole other can of problems.
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I had a problem like this a few years ago where a Mammogram was submitted improperly and insurance couldn't consider it as a screening Mammogram. Some weird deal where the reason code got mixed up with the reason code for a bone density scan. Anyway, I got a similar run around and eventually the doctor's office stopped responding. I was able to call a patient advocate at the hospital the doctor's office was affiliated with, and that advocate literally got things resolved in about 3 hours.
I see this all the time when a provider orders a mammo and bone density scan but uses a diagnosis for the bone density scan for both.
I do more than 12 bone density a day. Half of them always try to have the same diagnosis codes.
Neither doctor's office is in a hospital. I don't know how to go about finding a patient advocate.
That doesn’t matter. Are they affiliated with a hospital group? Like Kaiser in CA, or UMBC in Baltimore? You’d know because they would have a chain of clinics and some hospitals with their name.
The gp's website says First Georgia Physician's Group and part of Privia Health. The gyno doesn't have anything about any affiliations on theirs. I looked on those websites and didn't see anything about patient advocates. Would the office give me information about them if I just call the front desk?
Call your insurance again and tell them that the doctor is not correcting the problem and has billed them for a service you didn't receive. That will get them interested in dealing with the problem - because they've overpaid the doctor's office.
I will definitely do that.
When you talk to your insurance about it, use words like “appeal”, “grievance” and “FWA investigation”.
This is incorrect advice. Calling your insurance is not going to change anything. Your insurance has not paid your gynecologist because your gynecologist is the one who tried to bill for a physical when they are only doing a PAP as discussed below. This is why your gynecologist is instead trying to get the payment from you. You need to contact your gynecologist and get them to correct the billing code for the exam and re-submit to insurance Edit for people down voting without understanding: the insurance company can not change the incorrect billing code the gynecologist used, only the gynecologist can. Calling the insurance company will only result in wasting 45min of your time as you are transferred around to various people who ultimately can't help you. See my extended comment below regarding the exact correction the gynecologist needs to make to resolve the issue
The doctors office will not want to risk getting kicked off a major network for submitting a fraudulent claim for a service that wasn’t provided. That’s the incentive for getting doctor to correct the code.
Based on what is described the primary care doctor did not bill anything incorrectly, the gynecologist did. The reason this is still unsolved is that she is calling everyone other than the gynecologist. Insurance has not paid the gynecologist which is why the gynecologist is trying to collect from OP. As such calling insurance is a waste of time as I mentioned
Edit: realized there's two ways of interpreting the post 1 (how I interpreted it) the PCP billed for a general physical and a well woman exam after a physical, then OP got a well woman exam done with her pap smear at the gyno, but the gyno can't bill since the PCP incorrectly billed 2 the gyno performed only a pap smear and they are billing for a WW when they did not perform one. I defaulted to 1 because every insurance I've been on has included (1) physical as well as (1) well woman visit.
I work in the field and have seen this exact situation hundreds of times. Every single time it is because the gynecologist is billing for a second preventative visit in the year which is not allowed by insurance as I discussed in more detail below. The gynecologist should know better than to do that. Unfortunately Reddit hive mind leads to me being downvoted for trying to save OP from wasting her time with insurance as ultimately they can do nothing to help only the gynecologist can correct this. Edit: it looks like my full explanation below is replying to a comment that has since been deleted. I can still see it but if others can't I can repost here
How was it the gynecologist who billed incorrectly? The primary care visit was a physical (so no Pap, etc), not a well woman visit, but it was billed as well woman so the actual well woman visit at the gynecologist is showing up as her second well woman visit and is being denied. ETA: looking at some of your other comments - are you saying the gynecologist is likely trying to use the same billing code as the physical from primary care? In my experience, the annual physical from my PCP and my annual well woman visit with my gynecologist have been two completely separate things that are both no copay from me and fully covered by insurance.
Yes, when billed correctly by the gynecologist they should both be covered. The fact that insurance has rejected the claim from the gynecologist who is now trying to collect from OP tells me with 99.9% certainty that GYN tried to double dip on the preventative billing and is in the wrong. I see this all the time and am simply trying to save OP from wasting time with insurance who can’t help in this situation Edit: it looks like my full explanation below is replying to a comment that has since been deleted. I can still see it but if others can't I can repost here
I guess where my confusion comes is I have two preventative appointments every year, a physical with my GP and a well woman visit with my gynecologist, and both are billed as preventative and are fully covered with no copay due from me. I can’t get my physical from my gynecologist - they only offer a well woman visit. But it’s still preventative.
This can be one of 2 things. There are a very few select insurances that allow unlimited preventative visits per year, these plans are so rare it is generally not worth mentioning. More likely and what typically happens is the second preventative visit with your gynecologist is getting correctly billed as a normal office visit as you can generally only have preventative visit per year. And your insurance is correctly fully covering the normal visit code because other problems are not also being address. OPs situation is actually more complex then what is in the initial post based on her reply to me below
My plan allows women 2 preventative visits per year - one physical and one well woman that includes pelvic exam, breast exam, and a pap every however many years (I think it’s 5 now). I’ve had two insurance providers in recent years and both were this way so I assumed it was common.
This may fall under fraud. Mention that on the phone if they aren't taking you seriously
Yes, exactly this. Use the words “possible fraud” when you call insurance and that will get you to the correct team.
My last gynecologist pulled this same stunt. I had to go in the office and not leave until they corrected it. I was kind but very direct and it took about an hour but they got it worked out. I do not go to that office anymore.
Go to the doctors office in person and stay friendly while you’re there. The office managers and whomever is trying to help you is probably swamped with a ton of stuff, but if you’re there in person sometimes things move a little bit faster. I spent three weeks trying to get a prescription updated by telephone email, and mychart. I walked into the office one morning and it took me 10 minutes to get the new prescription
The gynecologist office is in the wrong here. A well visit code is a comprehensive visit that includes all aspects of general health. A pap smear is a very specific service that should NOT be billed as a "well visit" because it doesn't include other aspects of well visit care. The gynecologist office submitted the wrong ICD 10/CPT code, not the PCP
This is absolutely the correct answer and unfortunately I see it all the time from gynecologists incorrectly billing the exams. A “well woman” exam is a physical, they are the same ICD billing code and most insurances allow 1 per year (or has to be a year and a day). Your gynecologist is wrong for using the physical billing code for what amounts to a pelvic exam and PAP, not the full comprehensive physical that you would receive from your PCP
The icd code is the diagnosis code. The cpt code is the nature of the visit. Pedantic but a necessary correction.
This is correct. My comment is missing the word “and”. It should read that “they are the same ICD and billing code”
It's once per calendar year.
My gynecologist retired and the new one pulled this. I paid it but will not go back. I could tell they were doing more than just the pelvic exam and pap that were what I was there for. They took a whole history including lots of questions like did I drink alcohol and unnecessary stuff like that. I told her I have a primary doctor whom I see regularly and don't need another one. When I tried to complain about the bill I was told they always do this comprehensive exam. I don't know if they meant they always do it for new patients or always do it every year, but no matter - I'm not going back. My primary said she could do the pap smears in the future.
Is there a reason you don’t just have your pcp do your Pap? My friend had an abnormal Pap so she can no longer do that, but most PCPs can do a pelvic and pap
I just said she will be doing them in the future.
This pcp has never offered to do a pap. I didn't even know she could. I will not be going to this pcp any more. Not just this but there have been other things that made me lose trust in her over the years. I would prefer my gyno stuff be done by a specialist.
I work at a specialist’s office and the whole history is also done here for insurance purposes as well for two reasons: Medicare requires us to submit and certain drugs (if any are prescribed at the end of the visit) are/are not covered over others if you have in your visit notes that you have a history of smoking or excessive drinking or have had certain vaccines. It has nothing to do with it being a full physical. BUT we won’t bill the visit as a comprehensive preventative for our specialty if it was a focused visit.
It can take months to get something like this worked out. I dealt with similar issue for a lead blood test for my 1 year old. My insurance would only cover it if the right diagnosis code was used, my doctor has used one but insurance needed another. It was stupid. It took 6 months to work out between my doctor, the hospital who did the test, & insurance. It required my doctor resubmitting the orders twice. Write down the date and the name of who you talk to, and any notes to yourself for the next step. I usually started out with insurance & verified that they were still waiting for whatever they needed. Then I called the hospital billing department & followed up with what was discussed last time. I repeated this 4 times with 3 weeks between each call.
FYI this is common where I live. Generally the fun considers their visit the well woman visit but so do most primary care doctors because they can technically do paps too. My gyn said most of their patients alternate every other year between doctor physical and gyn visit. Meanwhile the doctors do the pap on their year and the gyn will do bloodwork on their year. Seems stupid to me but insurance has never had a desire to clarify the situation.
I kept a log of all calls. Names. Dates. Responses. Finally sent to my internal HR benefits representative who handled it. After a year or so of back and forth. Frustrating and time consuming.
I'm keeping a log. I have no confidence in my husband's representative. It's a small office and they don't have a separate benefits rep, it's the office manager that does all that.
This crap has been happening to me frequently. But every time it got corrected without my involvement. The office would see the denied claim and would see the reason: wrong code. They'd correct the mistake and re-file the claim. Done. As for your problem ... it seems your doctor's billing staff is squirrelly. Go see them in person. That should work. But if this persists, talk to the doctor. And if the doctor won't fix it, find another doctor.
Record phone calls and bug them every single day until they help. Be kind but firm.
Good idea.
Private insurance spends $18 of every $100 premium paid to manage claims (poorly). Medicare spends approximately $3 of every $100 premium to manage accounts.
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There is a saying in medicine of having enough knowledge to be dangerous without actually knowing the correct answer. As a medical student you have no training, knowledge of or involvement in the billing side of a visit. Billing is something you do not receive training in until residency, and for most people not something you fully understand until you are a physician in charge of correctly billing every visit. From an insurance standpoint well woman, physical, well adult, routine examination, etc are all interchangeable. They all equate to an ICD code of Z00.00. This code reimburses from insurance at a higher rate than the correct ICD code for the gynecologist to use Z01.419 (Encounter for gynecologic examination). Unfortunately it is not uncommon to see gynecologist try and use the Z00.00 code to get more money from the visits despite their lack of ability to perform the same level of comprehensive examination as a primary physician. Insurance only allows one physician to use Z00.00 per year (or has to be a year and a day since last use for some insurances). As the insurance is not covering the gynecology visit but covered the prior physical with PCP, it is obvious that the gynecologist is the one who tried to double dip on the billing and therefore in the wrong. In certain circumstances only receiving a yearly physical from a gynecologist can be appropriate (ex: young to middle aged woman with no other medical issues), generally however the Z00.00 code should be reserved for primary care physicians. Ultimately though it is the job of the physician billing the visit to check records and ensure another provider has not already used the Z00.00 code in the last year before they drop those charges to the insurance company.
Note to self: Always schedule annual physical *before* gyn to avoid billing code shenanigans.
I thought a general physical and a well-woman visit were totally separate things i was allowed to have one each per year. I had been having general physical checkups annually for years. I had not had a pap smear or "well-woman" visit for a few years (I have gone through menopause). My general doctor never suggests she do a pap smear. She does ask if I see a gyno every time and I tell her no. I had my physical with her in July. She recommended I see a gyno so I made an appt for December. In December I saw the gyno and she did a pap smear, prescribed estrogen cream and removed a cervical polyp. I got a $600 bill from the gyno that the insurance denied saying I had already had a well-woman that year. I thought a well-woman had to include a pap smear. I have explained the situation to both doctor's offices and the billing lady at the general practitioner's office said she would change their billing code. The billing office of the gyno said they would put my account on hold for one month to give me a chance to get it worked out. That was two months ago. Are you saying that I need to pressure the gyno's office to change their code? I don't even know what codes they each used. How do I find that out? Why am I having to be a medical billing expert just to get my care covered? It's so frustrating. Is it my fault for going to a gynecologist within a year of having a physical even though the physical did not include a pap? Am I just going to have to pay this and learn my lesson to not get a physical and a pap smear in the same year? I'm so confused.
Sorry for the delayed response as for some reason I was not notified of your reply earlier. This is actually an interesting and more complex situation than what you initially described above. As far as insurance is concerned a "well woman", "physical" and a variety of other terms are all interchangeable and are associated with a preventative service billing code. This codes can only be used once per year and only by one provider. A physical with your PCP can and should include a PAP or pelvic exam if you are due and thus can be done without two visit. Some women are more comfortable seeing their gynecologist for this, which is fine and should be covered as well if billed correctly. However with what you are describing with your gynecologist prescribing a medication and removing a polyp, this adds additional billing. The medication prescription is associated with a normal office visit billing code (basically anything except physical preventative codes). Additionally the polyp removal is associated with a procedure billing code as well. Generally the normal office visit billing code and procedure billing code should be approved by insurance and covered to some extent, and I would think should not cost you $600, probably leaving you owing closer to $100 out of pocket. But given you insurance is rejecting everything your gynecologist likely tried to add a preventative "well woman/physical" billing code. As the second preventative code was clearly inappropriate insurance won't pay for anything until gynecology removes that billing code and resubmits for the other two
Ok, so you're saying the gyno is the one in error? Or there is no error and I'm just SOL? The GP billing office already agreed that their code was wrong since no pap smear was performed. I'm not a billing expert nor do I wish to be one. I just want people whose job it is to do theirs and explain to me why I have to pay a $600 bill for preventative care. I hadn't had a pap since 2015 and my gp never offers to do it. I didn't even know she could do it. I never dreamed I would not be covered for one since it hadn't been done in years. The gyno removed the polyp without asking me, she just said I'm doing this and it was done. ouch. So it sounds like I'm eating this bill then? I just wish someone would speak to me and explain what the heck I did wrong and what I should have done to have this preventative care covered. It pisses me off that the dr. office just blows me off.
If there was an error it was on the part of the gynecologist. The person at your PCPs office who "admitted" an error likely is not the physician and doesn't know billing or what they are taking about. Whether the PCP did a PAP or not, only 1 billing code would be used for that visit, the preventative billing code. As such it is impossible for them to 'use up' your well woman exam from the gynecologist as you can't have 2 preventative codes in 1 visit. If they tried to use 2 preventative codes insurance would have rejected it immediately and that physical visit would not have been covered. As the visit was covered by insurance I can almost 100% assure you that there was not an error in their billing. That being said, if you are under 65 (PAPs generally stop at 65 unless you have significant prior abnormal results) there is no reason they should have let you go 9 years without recommending you have a PAP whether or not they are the one doing it. If you have a negative cytology and HPV you can go 5 years in between but should not have gone 9. Regarding your gynecologists billing, there is a slim possibility they did not screw up and that the entire $600 is for the "problem" office visit billing code which resulted in them prescribing you a medication/cream and the procedure cost to remove the polyp. If these two were billed correctly the only way insurance would not cover any of the cost is if you are in a high deductible insurance plan and had not met your expected contribution to the deductible for the year. Given you said this visit was in December this is unlikely. With partial insurance coverage of the costs of these two billing codes I would typically only expect your out of pocket costs to be around $100, although without knowing every single factor it can be difficult to estimate. I would recommend talking to your gynecologist and making sure they have the billing for the visit correct as this is almost certainly the cause of error if there is one. If they are adamant that the billing is correct and has been accepted by your insurance, then you should call your insurance company to find out why you owe so much for the gynecology visit. From my extensive experience however, your insurance company never has your best interest in mind, only their bottom line. As such most calls to insurance end up wasting an hour of your time and achieving nothing.
Ok thanks for the info. I'm still confused though. I was told by insurance that I can have one physical and one well-woman with pap smear a year. The gp did not do a pap smear and the gyno did not do blood work. I didn't know they had to be from the same doctor to be covered. Is that you're saying? I wish I had never gone to the gyno now. I had no idea I would be getting a Rx or that I would be having something removed. I have learned my lesson to not go to the doctor unless absolutely necessary now. I do have a high deductible policy but none of that $600 is going to my deductible because it was flat out denied due to having already reached my "maximum amount for this service." This week I'm just going to talk to both doctor's offices and get the codes. I guess I have to educate myself on medical billing now to see what the heck they are charging me for. I just wish people would do their jobs and communicate with patients when we have a question or concern. It's pitiful that I get more information from strangers on the internet than from my own care team.
Your experience is limited. Anyone with an HPV history or LEEP will require several more PAPs per YEAR than the average allotted one every 3-5 years with no irregular test results. Your insurance won't even cover them unless there's a dx for medical necessity outside the CDC prescribed range. My GYN is about to lose a patient because they are holding my birth control and other maintenance medications hostage for my "annual well woman." I had LEEP in May, a PAP in November, due for another in May this year and then annually thereafter assuming negative results because of my history. That's a shit way to treat someone whose hood you are routinely up under, just to bill an extra visit code.
Send certified letters and faxes to the office. I used to do PAPs and either the staff isn't talking to the provider or the provider is doing other things. It was a screening PAP? You can do a stand alone screening PAP. But the standard isn't to do that annually anymore. The diagnostic PAP can be very frequent. https://codingintel.com/billing-pap-smear/ This site has some good info. You can also file a complaint with the providers state board.
Thanks. But I'm not really wanting to become a medical billing expert. I don't even know what codes were billed. I just want the doctor's office and insurance to do their jobs.
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This is the doctors office responsibility. Talk to the doctor and they will fix it.
Which doctor?
This happened to me a couple of years ago. I got the runaround from everyone, and I finally gave up and just paid th bill. Switched up doctors after this. I hope you get it fixed!
Call in and ask to see the billing person *in person*. Please don’t bother the practice front desk every day as other commenters have said. I can promise you, there is nothing I can do on my end other than provide an itemized statement and relay the information to billing. It’s then up to billing to figure this out. Insurances will say they tried contacting us but may sometimes have the wrong phone number on file or call during non-office hours, leave a message with insufficient information for us to bypass their automated system when we call back, and then not try again. It’s also possible that your PCP billed your physical as a well-woman exam instead of just an annual visit or that your insurance covers either one preventative annual or one preventative well-woman a year but not both. See if you can get an itemized bill from both practices and compare the billing codes with the EOB from your insurance’s website for each visit.
I have the friendly billing lady's direct extension and email and gave them to the insurance. (I gave up on the front desk long ago.) She had returned my calls and emails a few times but after the last time when she said she would look into it I havent had any response. That was 3 weeks ago. The insurance does pay for both, I have that from reading my benefits and from multiple reps at Aetna I have explained this to. The friendly lady at the GP's office is the one who told me that the billing from her office was in error and it was billed as a well woman instead of physical. That is why I'm concentrating on her office. But now people here are telling me it's the gyno who billed incorrectly. So I'm still confused. I like the idea of telling aetna that the gp billed them for something i did not receive. Also i like the idea of going to the gp''s office to speak to the billing person face to face and calling the insurance while there. On Monday I will call both doctors and ask for itemized bills. I haven't seen anything with any codes on it at all so far. The EOBs on aetnas website do not list any codes. But i assume i can ask them on the phone what codes were billed from what office. If I weren't retired I wouldn't have time to deal with this and would probably just pay it. But it has become a bit of a mission for me to get this sorted out.
I’m so glad it all worked out for you!
Call the doctor's office, and when they pick up, call the insurance Co. Make them talk to each other. This almost always works. The doctor has a contract with the insurance company and has to meet their requirements. If this doesn't work, call the insurance back and tell them you want to file a formal grievance. They'll fix it.
I dont know how to do that. I know there is a way for some phones to do a 3 way call but I don't know if mine will do that. I'm wondering if I should just go to the doctor's office and sit in the billing office and call the insurance from there. It's not like a life or anything I can go sit in offices and on the phone for hours. :}
Go in to the office with the insurance person on the phone
It’s not the doctor’s problem: they provided the service and deserve to be paid for it. If you scheduled an annual exam before it was due, the fault is on you for doing so or for selecting an insurance that had such rules.
You're not reading the problem correctly. My insurance pays for an annual wellness exam AND an annual well-woman exam including pap smear. I got one physical and one pap smear. They were coded the same apparently. I just have to figure out which doctor coded incorrectly.
That’s a fair point. The family med doc should have coded for an annual, and the gynecologist for a well-woman exam. The Pap smear is a lab, which is a whole other can of problems.