Quote:
Originally Posted by Howitzer
Kerry,
although contracts differ I am sure with your attention to detail that you are correct.
The only thing you should have in your ass is the sigmoidoscope and $25; not the $400 bill.
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Here's what (last year's) policy says:
Preventive Care Services:
"One colorectal cancer examination and related laboratory tests are covered per Benefit Period regardless of age, or in accordince with the frequency determined by your provider."
On a separate page entitled Cancer Screenings, it says:
"Colorectal Cancer Screenings
Several types of colorectal screening methods exist. All plans provide coverage for colorectal cancer screenings, such as colonoscopies, sigmoidoscopies and fecal occult blood tests. Depending of the type of colorectal cancer screening received, payment for the benefit is based on the plan's provisions for laboratory servies, preventive care office visit services or other medical or surgical services. Our plans do not provide coverage for preventive colorectal cancer screeings involving invasive surgical procedures and DNA analysis."
The question is: What does this mean? One the one hand it says it provides screening coverage for colonoscopies, on the other hand it says it doesn't provide coverage for invasive procedures. On the phone they say a colonoscopy is an invasive procedure. My PCP ordered a preventive screening.
I've beaten them once before on the wording of their policy once I pushed the issue to an external review board. I've got to try to figure out what are the possible interpretions of these paragraphs. It seems to me that one could construe the first part of that paragraph to say that they do cover a colonoscopy as a screening procedure and not an invasive procedure.
They must be aware of the ambiguity because on the phone they are very touchy about discussing the issue.