Linda Brandwin, R.N. Linda Brandwin is a registered nurse and a medical billing and claims specialist. For the past 10 years she has worked directly with insurance companies to give advice and guidance to the health care consumer. Readers may send email or write Linda Brandwin at 5500 Single Oak Hill Ct., Woodbridge, VA 22192.

'Preventive medicine' procedures aren't always covered
April 23 , 2004

Q: I received an explanation of benefits from my insurance company denying my claim for a pap smear procedure for my wife. The clinic billed the procedure as preventive medicine and pap smear and my insurance does not pay for preventive medicine claims. My wife receives an annual pap smear upon the recommendation of her doctor since she has a history of female problems.

I questioned the billing supervisor and asked if the charges could be rebilled as "doctor's recommended procedure" which it is. The supervisor said the appointment was booked as an annual pap smear and that is preventative medicine. She said she will not resubmit the claim because that would be fraudulent.

I wrote to my wife's doctor and she spoke to him regarding this matter. He said he would confer with his billing supervisor and he did agree it was a needed procedure. I explained that my insurance company said that if the provider service had been billed as a regular doctor visit, they would have paid on this procedure.

I have not heard anything further from the doctor's office and I have paid my bill. But now I am further worried because my wife is due to have a colonoscopy and this is quite an expensive procedure. Her father and brother died of colon cancer. We are worried the clinic will bill this as preventive medicine and we will get stuck with the full amount of the bill for this procedure too.

To me it appears that the health providers and insurance companies are placing patients at risk due to their bickering problems. I just thought you would want to know what is going on.

A: Many people would agree that all of the rules and regulations of insurance companies make it difficult for patients to receive the best medical care possible. Your particular plan with your insurance company does not provide coverage for preventative medicine. Insurance companies can be short-sighted regarding this lack of coverage. It is actually far cheaper for an insurance company to pay for a screening pap smear than treating a patient who has an advanced gynecological disease that could have been caught in the early stages by a simple pap smear.

A pap smear is a screening procedure. Your wife is, fortunately, healthy. Although she is at risk for a gynecological disease because of her female problems, she has no disease currently. Therefore, the pap smear really is preventive. You can look at this as a small price to pay for being healthy.

If the doctor had seen your wife for something other than an annual well-woman check-up, he could have billed the visit as a regular office visit and a pap smear. For the office visit, he would use a diagnosis code that would indicate the reason your wife needed the exam. He then would use a diagnosis code for the pap smear that would indicate your wife has no disease currently but is at low or high risk for developing a gynecological problem. I do not know if your insurance company would pay for this claim either. It is something you would have to discuss with your wife's doctor and your insurance company before her next pap smear.

Before your wife has the colonoscopy, call her doctor. Ask him what procedure code and diagnosis code he will be using for this claim. Then call your insurance company and ask if they will cover this procedure with this diagnosis code for this particular doctor and clinic. Just because they don't pay for pap smears, does not necessarily mean they will not pay for a colonoscopy. There may be deciding factors the insurance company needs to know in advance, such as your wife's age and medical history, in order to make a coverage determination. Solving an insurance problem before it becomes a problem is the best preventive medicine. As always, document all phone calls.