UMR did not cover OBGYN follow-up appointment for treatment plan
Hi from North Carolina- I am very new to the ways of health insurance and have tried to read up on this as much as I can, but am still struggling to understand the situation. TIA for the long-winded read and any wisdom you can offer- it is much appreciated.
I believe I do not have a deductible and am a dependent of insurance with my family.
I started seeing an OBGYN this year after many years of dealing with painful, severe periods and debilitating depression in the weeks leading up to them. After a initial office visit and pap smear/pelvic exam (copay), I had an ultrasound and blood testing (either copay or 100% covered diagnostic testing).
My physician ordered a follow-up appointment to the ultrasound to discuss the results and further treatment (mainly birth control). I attended this appointment, and we discussed my ultrasound results and what may be my issues with PCOS. We discussed hormonal birth control pills to help the heavy bleeding and the suspected hormonal issues. For one of the top birth control choices, we agreed to order a blood test to test for genetic clotting issues that would make the pill dangerous. I told her that I wanted to wait to order the birth control so I could think more about this option even after the test results returned. I would prefer to begin exploring antidepressant/SSRI treatment options with my PCP before I begin experimenting more with my hormones and trying my luck with birth control side effects- especially since I am planning to not be sexually active.
I receive notice from UMR that my insurance will not cover any of a $255 bill from the follow-up appointment and I was unable to find a statement that describes why this was not covered. I call the OBGYN office and they state that the appointment was entered under Z30.09 (Encounter for other general counseling and advice on contraception), F32.81 (Premenstrual dysphoric disorder), Z82.49 (Family history of ischemic heart disease and other diseases of the circulatory system), E80 (Hereditary erythropoietic porphyria), E28.2 (polycystic ovarian syndrome)- but was being considered as Routine Care due to the first code of contraceptives counseling.
I talked to UMR briefly to understand that I do not have full Routine Care coverage, just for “Routine physical exams (In and Out-of-network) Routine diagnostic tests, lab and X-rays (such as
routine mammograms, pelvic exams, pap test, and prostate exams/tests) (In and Out-of-network)” among immunizations and routine eye exams (all which would have a copay). I do have coverage of what is titled Physician Services*, with no further list of what “physician services” include. I have a copay for this.
* Can anyone explain what Physician Services entails?
I called the OBGYN office again and they stated that the difference between my first appointment was that it was considered an “appointment for a problem” whereas the subsequent follow-up appointment was “majorly for contraceptives which would be considered wellness and routine care since there wasn’t a problem”- which to me seems incorrect, as the only reason we were discussing birth control and the corresponding labs is as a treatment plan for the PMDD and hormonal issues corresponding to my polycystic ovaries. The follow-up was only occurring for the problems that I was continuously having.
*Needing advice- I am unsure if I should accept this or if there is an explanation for why this may not Routine Care, and is instead Physician Services/etc. Do I need to enforce that this was for recurring issues and not simply for general contraceptives counseling? I feel silly to have gone in for a 10-20 minute office visit with no copay to get the physician to order my blood lab test, though she ordered that I come in for a follow up to discuss all of my results and my treatment plan before moving forward.
I have no idea if I can file a claim with either UMR or my health providers, or if I need to call back to talk to them. Let me know if you have any insight into this situation!
