BCBS: Not covering “Medical care” associated with standard office visit

Should I be charged and pay for “medical care” above and beyond a standard follow-up office visit if no exam is done and no actual treatment is provided? Is this standard and ethical billing on the part of my provider that has been happening all along but the insurance (BCBS) is suddenly not covering it anymore?

I’ve had Blue Cross/Blue Shield for about 15 years, and increasingly over the past three years or so I’m seeing more and more denials of benefits. Some of the charges seem a little questionable to begin with, and I don’t know if the providers are charging for what they are actually providing.

Here is the most recent example. So far this year I’ve had two different providers in two different medical groups bill the insurance for “medical care” above and beyond the standard office visit. I am charged the co-pay ($45) for the office visit, but BCBS denies the second charges for the medical care.

The code is 165: Benefits are not provided for any service identified as non-covered in the service benefit plan brochure. Likewise, benefits are not provided for a covered service when the reason it was performed is not covered. Therefore, I am responsible for paying them.

The price is not negotiated, so I am responsible for the full amount. Then I get a bill from the provider to pay for this “medical care”. For example, one is $50, which is more than the co-pay itself. I am not warned up front that I will be charged this, and I have never been charged for it before this year. So I end up paying more than twice as much as I expect when I walk in the door.

It’s not bad enough that my co-pays went up $5 per visit this year, but now I’m also supposed to pay for some phantom “medical care“ I don’t remember receiving?

The problem is, I’m receiving nothing that I understand to be medical care above the regular office visit. In both cases, these visits were follow-up, not new patient visits. I don’t even see the doctor. I see a nurse practitioner. At no time does the NP listen to my lungs and heart, provide a neuro exam, or give me any kind of therapy, injection, or other kind of treatment. Basically, I sit in a chair for ten or fifteen minutes and answer questions, list new symptoms, and maybe get a new prescription.

And yet, unlike at any time before, I’m get surprised by a bill weeks later saying I owe them for ”medical care” in addition to the office visit.

So my questions are:

1) Are these legitimate charges?

2) If not, do I contact the insurance and let them know the providers’ billing practices need to be investigated?

3) If they are legitimate charges, how do I go about trying to get insurance to cover it? Or how do I negotiate like the insurance to get the charges lowered?

4) How do I avoid being surprised by these BS charges in the future?

Thanks!

submitted by /u/Burnt_Out_Sol
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