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advice on insurance coverage for echocardiogram
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sexy topic for a thread, I know.

short version:

wife reads about deaths in triathlon/marathon, wants me to get heart checked.

I read ST articles about OWS/heart incidents--& though I've never had a panic attack or any incidents--I agree.

Go for initial scan. Dr detects "non-specific, very general" abnormality. It's been months, I don't remember the details. He prescribes echocardiogram & stress test.

I get echocardiogram at hospital. Keep postponing stress test.

Hospital bill for $2,846 arrives, along with explanation from Anthem's Dr explaining that since I had no pre-existing dangerous symptoms or conditions, Anthem BC will not cover the cost of the treatment.

Right now the ball is in my cardiologist's court for follow-up with Anthem BC.

Have any of you had success with a particular type of claim or symptom/condition in this instance that passed muster with your insurance company? thanks.

_____________________________________
What are you people, on dope?

—Mr. Hand
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Re: advice on insurance coverage for echocardiogram [scofflaw] [ In reply to ]
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My insurance paid for mine in full....


I'm confused, are you looking for a way to fraud the insurance company?
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Re: advice on insurance coverage for echocardiogram [scofflaw] [ In reply to ]
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I'm not sure I understand your situation. Did the doctor mislead you that it was covered? Or is it that you didn't find out ahead of time if it was covered?

I was in a similar situation but I collasped/feinted after a race...ended up in emergency room and then cardio unit for about a week. But I make sure the insurance would cover everything before they ran all the tests.
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Re: advice on insurance coverage for echocardiogram [scofflaw] [ In reply to ]
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You'll owe.

Call the hospital's business office and offer a payment plan of $300 a month and pay it over several months.
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Re: advice on insurance coverage for echocardiogram [Old Carolina] [ In reply to ]
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Our healthcare system is incentivized to find loopholes and not pay.
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Re: advice on insurance coverage for echocardiogram [Old Carolina] [ In reply to ]
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My insurance sucks too. I've had 2 stress tests w/ultrasound, ECG, over the last 7 years. Each time I ended up owing about $700.

The $700 was worth the piece of mind I have while training knowing I can push myself to the limit without having a heart problem.

The cardiologist said the it will soon be a routine procedure for HS athletes.
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Re: advice on insurance coverage for echocardiogram [scofflaw] [ In reply to ]
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Insurance companies require diagnostic criteria -i.e. the indication for doing the test. Concern is not a symptom and therefore not an indication. The echo actually wouldn't diagnose atherosclerosis- the plaque problem that results in a plaque rupture and consequent artery blocking thrombus (clot) or sufficient narrowing to cause a rhythm disturbance due to ischemia of the heart muscle (insufficient blood flow to deliver adequate oxygen). Echos in otherwise healthy people sometimes detect valve issues (e.g. mitral valve regurgitation) which in early stages are typically not life threatening. A non-nuclear stress test can indicate ischemic changes in the wave form which can be diagnostic, but is a blunt instrument compared to nuclear imaging or catheterization -both of which are very expensive tests -and equivalent to hundreds of chest x-rays in terms of exposure to ionizing radiation.
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Re: advice on insurance coverage for echocardiogram [scofflaw] [ In reply to ]
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scofflaw wrote:
sexy topic for a thread, I know.

short version:

wife reads about deaths in triathlon/marathon, wants me to get heart checked.

I read ST articles about OWS/heart incidents--& though I've never had a panic attack or any incidents--I agree.

Go for initial scan. Dr detects "non-specific, very general" abnormality. It's been months, I don't remember the details. He prescribes echocardiogram & stress test.

I get echocardiogram at hospital. Keep postponing stress test.

Hospital bill for $2,846 arrives, along with explanation from Anthem's Dr explaining that since I had no pre-existing dangerous symptoms or conditions, Anthem BC will not cover the cost of the treatment.

Right now the ball is in my cardiologist's court for follow-up with Anthem BC.

Have any of you had success with a particular type of claim or symptom/condition in this instance that passed muster with your insurance company? thanks.
_____________________

If your physician felt it was medically necessary for you to get these studies then they should be covered under your insurance ..... so long as the physician was a network physician and the facility was in-network.

The key is how the physician billed your insurance (what codes were used) .... clearly if he said it was "preventive care" rather than for evaluation of a possible condition, then you will be stuck for the bill. What his office notes say regarding the visit are also important (request then from him). He could resolve it all by talking with your insurance and justifying a non-preventive purpose. I also suspect unless you are over 45 that there would need to be some clear reason.
Also note that your procedure was done at a hospital and therefore the huge bill when you probably could have obtained that procedure for $350 cash ( that is about what insurance would pay).
The hospital has its own billing department and may not have even asked the physician what the reason was .... they obviously have a vested interest to try to bill you for the $2900 rather than $350.
Be careful that they just offer to rebill the insurance without changing the billing codes .... the outcome will be the same and they will tell you that it still was rejected.

You can appeal this to your insurance company through their required appeals process. Your reason needs to be that you were advised to have these tests by one of their network physicians and you're not a doctor to know any different .... you just followed his advise ( be sure his note doesn't state he told you it wasn't covered). The appeal process is a bit devious. Your first level of appeal will be an expected automatic denial again. If you persist with a second level appeal, you have a high likelihood of prevailing. If they deny you the second time you probably have the right to appeal to the state insurance commissioner who will highly likely make them pay if it was advised by a network physician.

In the meantime you may want to try to negotiate a payment with the hospital .... $350 would be a market price but they are not bound to accept that.

Again .... your physican can resolve this for you easily if he will choose to get involved.

Dave
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Re: advice on insurance coverage for echocardiogram [scofflaw] [ In reply to ]
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It seems like different insurance companies have different conditions under the law. For example my agency solved this problem easily, and other companies i heard about had some difficulties
Last edited by: Slowman: Jan 29, 18 6:34
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Re: advice on insurance coverage for echocardiogram [scofflaw] [ In reply to ]
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I paid a little over $400 for mine but I also have a heart murmur they were checking out.
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Re: advice on insurance coverage for echocardiogram [scofflaw] [ In reply to ]
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2019$ for two echos that give non-specific results? That is theft.

They constantly try to escape from the darkness outside and within
Dreaming of systems so perfect that no one will need to be good T.S. Eliot

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Re: advice on insurance coverage for echocardiogram [len] [ In reply to ]
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This is a area near and dear to my heart, no pun in intended. I have had an echo stress test every 2 times in the past 8 years and just recently had a nuclear stress test (well that is because I had a heart attack 8 years ago). But even with insurance and all the other fun stuff I usually pay about 500 for each stress test (not sure how much the nuclear will cost me), but my theory is if the doc say you need it, go get it even if the insurance says no. I would rather be out 2K than out my life. The biggest cost for the stress test is the time it takes to have 3 people (cardiologist, ultra sound technician, and person running the test) sitting in a room with you while you run on a treadmill.
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Re: advice on insurance coverage for echocardiogram [dcsxtri10] [ In reply to ]
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dcsxtri10 wrote:
scofflaw wrote:
sexy topic for a thread, I know.

short version:

wife reads about deaths in triathlon/marathon, wants me to get heart checked.

I read ST articles about OWS/heart incidents--& though I've never had a panic attack or any incidents--I agree.

Go for initial scan. Dr detects "non-specific, very general" abnormality. It's been months, I don't remember the details. He prescribes echocardiogram & stress test.

I get echocardiogram at hospital. Keep postponing stress test.

Hospital bill for $2,846 arrives, along with explanation from Anthem's Dr explaining that since I had no pre-existing dangerous symptoms or conditions, Anthem BC will not cover the cost of the treatment.

Right now the ball is in my cardiologist's court for follow-up with Anthem BC.

Have any of you had success with a particular type of claim or symptom/condition in this instance that passed muster with your insurance company? thanks.
_____________________

If your physician felt it was medically necessary for you to get these studies then they should be covered under your insurance ..... so long as the physician was a network physician and the facility was in-network.

The key is how the physician billed your insurance (what codes were used) .... clearly if he said it was "preventive care" rather than for evaluation of a possible condition, then you will be stuck for the bill. What his office notes say regarding the visit are also important (request then from him). He could resolve it all by talking with your insurance and justifying a non-preventive purpose. I also suspect unless you are over 45 that there would need to be some clear reason.
Also note that your procedure was done at a hospital and therefore the huge bill when you probably could have obtained that procedure for $350 cash ( that is about what insurance would pay).
The hospital has its own billing department and may not have even asked the physician what the reason was .... they obviously have a vested interest to try to bill you for the $2900 rather than $350.
Be careful that they just offer to rebill the insurance without changing the billing codes .... the outcome will be the same and they will tell you that it still was rejected.

You can appeal this to your insurance company through their required appeals process. Your reason needs to be that you were advised to have these tests by one of their network physicians and you're not a doctor to know any different .... you just followed his advise ( be sure his note doesn't state he told you it wasn't covered). The appeal process is a bit devious. Your first level of appeal will be an expected automatic denial again. If you persist with a second level appeal, you have a high likelihood of prevailing. If they deny you the second time you probably have the right to appeal to the state insurance commissioner who will highly likely make them pay if it was advised by a network physician.

In the meantime you may want to try to negotiate a payment with the hospital .... $350 would be a market price but they are not bound to accept that.

Again .... your physican can resolve this for you easily if he will choose to get involved.

Dave

This!

But seriously, if you do unnecessary tests like a CT, you will often find some anomaly. That leads to other test. In the end it will cost you and the health care market a lot of money.
Just tell your wife that $2000 could have been a new bike or clothing, shoes, or nutrition.
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Re: advice on insurance coverage for echocardiogram [mclousing] [ In reply to ]
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I got the impression the OP just got two echos and no echo stress test. I can see a stress echo being expensive but an ordinary echo that much? The other issue is doing stress tests on asymptomatic individuals with no cardiac history/symptoms can lead to false positive. Then you possibly get an angiograms which carries some risk of a stroke.

They constantly try to escape from the darkness outside and within
Dreaming of systems so perfect that no one will need to be good T.S. Eliot

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Re: advice on insurance coverage for echocardiogram [len] [ In reply to ]
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FYI- 4 year old thread necro'ed by a since banned spammer it appears.
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Re: advice on insurance coverage for echocardiogram [scofflaw] [ In reply to ]
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Yah, my wife had the exact same concern with all of the recent articles. I went over this with my GP (a runner) and he listened and did the normal EKG, etc. Note I have had some tachycardia in past. He felt that there was no indication whatsoever for further testing and the the possibility of red herring benign anomalies would drive me crazy. Had cardiologist friend review my ekg and he had the same opinion. Certainly I could drop tomorrow, but I guess that would have happened anyway. For now, I'm not worrying about my heart.

David
* Ironman for Life! (Blog) * IM Everyday Hero Video * Daggett Shuler Law *
Disclaimer: I have personal and professional relationships with many athletes, vendors, and organizations in the triathlon world.
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Re: advice on insurance coverage for echocardiogram [elf6c] [ In reply to ]
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elf6c wrote:
FYI- 4 year old thread necro'ed by a since banned spammer it appears.

It’s odd to see this thread revived.

I’m the OP. Who is the banned spammer you mention?

_____________________________________
What are you people, on dope?

—Mr. Hand
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