OP asks for help after insurance company denies claim for wife's childbirth citing "not a medical necessity", someone who works in medical billing responds with the exact solution down to billing codes and how the error was made

OP asks for help after insurance company denies claim for wife's childbirth citing "not a medical necessity", someone who works in medical billing responds with the exact solution down to billing codes and how the error was made
OP asks for help after insurance company denies claim for wife's childbirth citing "not a medical...

Insane that they would implement a system that isn't backwards compatible - I can't imagine how many of this type of error happens during this transition.

Most of the time, you should be able to look at an ICD-9 code and an ICD-10 code and tell instantly which one is which, because an ICD-9 starts with a number, but ICD-10 starts with a letter.

Where they fucked up was by adding ICD9 codes that begin with E and V to the mix (https://en.wikipedia.org/wiki/List_of_ICD-9_codes_E_and_V_codes:_external_causes_of_injury_and_su...). When I had to load in ICD10 codes for some software that my company uses, I thought "Surely the fact that these E and V codes exist must cause a lot of errors out in the field" and indeed, they do.

This reminds me if the time my insurance decided my radiation treatment wasn't medically necessary to treat cancer. Took over a year to sort out because they kept "losing" the approval note stating that they've agreed to cover it. We faxed it to them four or five times reminding them that they did in fact agree to cover it. Then they tried to apply it to following year's deductible. Fuck insurance companies.

This has to be one of the best "BestOf" submissions ever. Plus, the comments go on to explain why signing a consent form allowing future research tests during a hospital stay can lead to serious overbilling.

I'm so glad I'm subscribed to this reddit!

My son was born via c-section as the doctor deemed it medically necessary for, you know, him to live. The insurance company initially rejected our claim and called it an elective surgery. Having a mother-in-law who worked for years with ICD-9 billing was a godsend when that happened. It still baffles me that we put the health of our citizens in the hands of a profit-driven industry.

CMS announced this change was happening in 2008, and it wasn't implemented until 2015. It's not exactly a big secret that this was happening. Frankly the people billing I-9 codes should be embarrassed.

Also, this potentially could have been a technical issue on the software side if the site was dual coding for some reason.

A few years ago my boss's wife broke her back. Their insurance wouldn't cover the ambulance ride because they didn't feel it was "medically necessary".

The code system has nothing at all to do with insurance companies. It's an international standard agreed on by most major countries to facilitate inter-language communication and statistics gathering. It's been co-opted by private companies because it's much simpler than the alternative and is used by the CDC, the DOH and other government entities.

So glad I live in a country with free health care. The fact that this wasn't his fault but has to go through that tedious shit blows my mind. Can't just call the insurance company and say hey wtf? Have someone look at the request and go... Oh yea it was imputed by us wrong.

And to share a pregnancy code with a motorcycle accident code of all things, it sounds crazy to my mind. I can picture the guy on the phone with the billing office: "But you can't do this, my wife is pregnant!" "If your wife is pregnant sir, then why was she riding on a motorcycle?" "Uhh...are you sure we're talking about the same patient?" "How many wives do you have?"

It just amazes me how bad the American healthcare system is fucked.

As a Canadian, the biggest billing issue I ever had was when I went to the ER after a bad skiing wipe out, without my wallet. A couple of weeks later, I received a bill in the mail, saying I wasn't a Canadian resident. I headed over to the hospital with the bill, told the receptionist that I was in fact Canadian, and showed my health card. She typed a few things into her computer, and told me everything was straightened out. That second trip took less than 5 minutes,

How much man power is wasted in the US just handling an insane billing system?

For comparison: I'm in the UK. A few years ago, my wife was admitted to hospital for a few days. A few days after she'd been discharged, she got severe chest pain and breathing problems. We'd been told to take any chest pain seriously after her hospital stay, so we called the ambulance.

Turned out it was just a severe panic attack.

Despite that, the ambulance people sat down with her, calmed her down, walked her through some breathing exercises, checked her thoroughly, stressed to us to call again right away if we were the least bit worried, given the very serious possible causes of chest pain, and not to worry about whether it might turn out to just be a panic attack again. Took our details for their reporting, and drove off.

I'm so happy I don't ever have to try to assess whether or not something will be considered "medically necessary" before calling an ambulance or otherwise using the health service.

That any of this is necessary boggles my mind every time I see stuff like this.

American health care is fucking ridiculous.

I'm so glad I'm subscribed to this reddit!

"That'll be $4500"

Reddit if bought by an insurance company.

They are literaly scum. Pekin insurance had my parents sign a bunch of stuff that absolved them from paying for my burn unit bills just days after i was burnt. My parents dont even remember signing them since they themselves were in shock. And thwre is no use taking them to court either.

What's even more interesting is that ICD-10 was starting to be developed in 1983 and was finally completed in 1992. It was then adapted in other countries several years later (around the early 2000s) and it took the US ages to switch over.

Source: work in hospital billing and here

Edit: I need to proofread more

Yeah, especially when something as common as childbirth has this exact error :-(

Somehow half of America has bought into the idea of trickle down economics. The only explanation I have is an old one: every American views themselves as a temporarily embarrassed millionaire... That or they just don't give a shit about other people. They'd rather have a lower monthly premium than help out those with pre-existing conditions.

Honestly, I'd willingly pay a fuckload in taxes if that meant true single payer healthcare. I pay about $300 a month pretax through my employer (just for myself) for a $3000 deductible plan. Even with insurance, I have actively avoided going to the doctor. I'm 26 and haven't had a physical since I started high school. So, if I were to ever get seriously sick, I'm basically going deep into credit card debt. Single payer can't truly be that expensive, even accounting for the inefficiencies of government.

Respectfully disagree. For one thing, this was 2003, long before conversion to ICD-10. The problem is we got a bill for a ton of money from several different providers, based on someone in the chain deeming the procedure elective. (Generally, parents don't simply "elect" for a surgery when an umbilical cord is wrapped around the child's neck. They follow doctor's orders.) My mother-in-law fortunately knew the system and could navigate us out of it. There are plenty of people who could be screwed because they don't know how to navigate the waters. I still stand by my last statement.

It still baffles me that we put the health of our citizens in the hands of a profit-driven industry.

This is a bit of a non-sequiter if was an ICD-9 conversion error. Government employees and government systems also make these mistakes.

The letter I and number 1!! Ugh, who didn't foresee that one being a problem?

Fuck those consent forms. They just shove paperwork at you to sign and dont explain any of it. Taking advantage of sick people is there a lower bar?

Even in places where medical care is considered a basic human right, like Canada, the UK, France, Germany, and Sweden, ICD-10 codes are used.

The difference here is that a mistake can affect an individual's finances rather than mess up statistics.

But that's the thing. There are crosswalks from ICD-9 to ICD-10 but, when submitting claims, the Date of Service is looked at first. If the date of service was on or after 10/1/15, ICD-10 codes are required. The payer isn't going to look up the crosswalk because those were th3 rules put forth when we made the switch. The "medical necessity" rejection is likely not the actual reason and was just simply what the biller marked down for some reason or was explained to the patient incorrectly. The rejection message/code would clearly indicate that ICD-9 codes were sent for DOS after 10/1/15 which is why the claim was rejected.

Privatized death panels are the best. Keep the govment outta my death panel.

Lack of specificity is a different issue than the posted one. Your insurance is probably making sure that your hospital isn't trying to scam them.

See, ICD-10 codes are structured in a detail hierarchy, and they change depending on how much detail is provided. For example, let's say you fractured your femur. If the doctor just records "femur fracture", with no other details given, the ICD-10 code is the default S72.90XA. But if the doctor records that you have a type I or II open fracture of the head of your left femur and this was your first appointment, the ICD-10 code becomes S72.052B. Or if you had a closed nondisplaced fracture of the greater trochanter of your right femur and this is a follow-up appointment and it hasn't been healing as well as expected, the code becomes S72.114G.

The reason insurance cares about this is because treatments, and therefore treatment costs, can vary depending on the specifics of the diagnosis. What the insurance company is probably trying to avoid in your case is a situation where you had a routine, low-cost birth, but the hospital sends them a vague "birth" code and then tries to charge for a very complicated and expensive birth. Billing like that (when done on purpose) is a fairly typical type of insurance fraud.

My (least) favorite time dealing with insurance was when I had to get a colonoscopy because my doctor wanted to confirm the severe case of ulcerative colitis he was sure I had. For 2 months, I had severe abdominal pain 24 hours a day, nonstop bloody diarrhea, and had lost 20 lbs due to my body not digesting food.

Because I needed this procedure, it was considered "diagnostic" and not covered by insurance, meaning I had to pay up to my deductible of $1500. The price range was $600-1200.

If I had been a 65 year old man with absolutely no health problems, it would have been "preventative" and therefore done at zero cost.

Makes perfect sense. Charge the people who need the services, and don't charge the people who don't.

We can't have real healthcare in the US because there would be death panels that decide who lives and who dies.

I don't know how that would be different from an insurance company though.

I have no idea what the stats are off the top of my head, but nonprofit does not mean not business driven. Money drives nonprofits just as much as it does for profits.

In countries like Australia, we look at your healthcare system in awe. How do you not have universal coverage?

Money. Not expense, but loss of profit.

The code system has nothing at all to do with insurance companies. It's an international standard agreed on by most major countries to facilitate inter-language communication and statistics gathering. It's been co-opted by private companies because it's much simpler than the alternative and is used by the CDC, the DOH and other government entities.

Funny thing about government spending on healthcare. The Canadian government pays slightly less per capita on healthcare, than the American government, but while we have everyone covered, the US government only covers those over 65 and the poor.

What I find saddest about the American system, is how much freedom you lose because of it.

For a good chunk of my 20's I was a ski bum in the winter, working just enough for food and cheap rent (my season pass was included in my job), and skiing almost everyday. I didn't have to worry about what would happen if I got sick. And if I did need care, I would get great service with no hassles.

Americans on the other hand can be stuck in a job they can't quit, because they have a condition that a new policy, at another job, would never cover.

And when you do need to go in for care, you need to fill out a ton of forms, prove that the provider will get paid, before a doctor will even look at you.

In the story I mentioned above. The doctors were all over me, made sure I was stable, then asked for my information. When I told them I didn't have my health card on me, and didn't know my number, they didn't stop treating me, they went on with only my name and address.

As I mentioned, the convoluted billing in America makes healthcare extremely inefficient. At my doctors office, 4 doctors share 1 secretary. From what I understand, most offices in the US require several secretaries just to handle billing.

Add into that the fact that the players in healthcare who have power to make choices all want higher costs (providers and insurers), and the people who need healthcare have no choice but to pay insane prices for either insurance coverage, or even worse, pay for treatment out of pocket.

You spelled "a fucking cesspool of greedy for profit companies whose motive is to make as much money as possible without any thought for their customers well being" wrong.

Dude. I write sql and npr reports for this.

Icd10 codes are all one length now, finally, and I think that errors will eventually decrease.

My advice, don't use a hospital for the next 5 years and let them get the kinks out

Pregnancy isn't medically necessary, but is protected by law, so it has to be covered by insurance.

There are a ton of things that are arguably not necessary medically, but are still covered by insurance and/or Medicare/Medicaid)

Holy shit. I just started working as a clinical coder on the first of the month and we use ICD-10. My job is relevant on reddit!

I can't even count the number of times I've accidentally mixed up childbirth with a motorcycle accident.

And yet, I shit you not, Americans tell second-hand anecdotal stories about how inefficient and terrible the Canadian healthcare system is. Don't forget, your insurance doesn't kick in until you meet your deductible. After that, you're on the hook for ~60% co-pay until you reach your maximum out of pocket annual expense (which for me is 10,000)! Even routine medical expenses in the US are financially ruinous. Also, we spend basically nothing on public health initiatives. I just don't understand the opposing viewpoint. How can anyone be for private health insurance? How is the "free market" supposed to operate when a patient will literally die if they refuse treatment?

We pay a ~25% premium on healthcare costs in the form of insurance company overhead, and somehow still stupid shit like this happens. Come the fuck on.

Single payer now.

People who aren't in the medical industry would take a letter that said "PR50: These are non-covered services because this is not deemed a 'medical necessity' by the payer" to mean what it says and not think "oh I bet the doctor's office typed in some obscure numbers wrong and this will be easily fixed."

When my sister was shot in the neck, the insurance company tried denying her because months prior they had a billing dispute. My sister's credit card was stolen, so she had to call to cancel it, and she forgot to update the billing information for insurance.

That was fixed the next month, and they mailed her a letter confirming that she was up to date.

So, when she was shot a few months later, they tried claiming that she was not covered, and my mother had to leave my sister's side, not knowing whether she would live or die, to dig through my sister's files to find that letter they sent.

They know damn well that she was up to date. They must've had a copy of that letter on their own file, and they would've had the billing history to show she was paid up to date. They were just hoping we didn't have the paper and hoping we weren't in the right mental state to fight it.

I find it hilarious how people who are ignorant of international healthcare systems say "but they have complaints about their system! it's so inefficient!" Yes, they do have complaints. Like, if you have a benign mole which you'd like to have removed, you might have to wait a month for the appointment or something. They'd like to get it earlier.

Meanwhile, the complaint in America is that YOU DIE. So, maybe different things.

There is literally no possible way that it could be less efficient than our current system. None:


There is literally no possible way that it could be less efficient than our current system. None:

They should probably fix that

Oh no, you have to pay the whole thing. We decided that it wasn't a medical necessity.

Why would they? It's in an insurer's best interests to delay / deny coverage whenever legally allowed and this helps them do exactly that.

Sure, because lord knows people who can't afford medical care in those countries are the ones most able to pack up and leave.

OP received a $4000 bill with very definitive language on it and asked reddit what they should do. Hardly seems out of proportion.

Children? Taking advantage of children might arguably be lower.

As someone who had to deal with that transition--it actually wasn't nearly as bad as a lot of people expected. The transition date got pushed back multiple times, so even the entities that procrastinated a bunch were largely OK. There is some overlap between codes, but for the most part it's fairly easy to tell them apart.

That said, the fact that this office managed to send out an ICD-9 claim at this point is pretty silly. Someone, or something, fucked up quite hard.

that is fairly common in my experience. If they insurance doesn't pay then the bill is send along to the patient.

It amazes me that Americans who are so insistent on efficiency and productivity have built the most ridiculous, inefficient, outdated, error prone health care system in the developed world. And this is a huge % of our GDP.

The money that is wasted each year in bureaucracy to "manage" this broken system is almost incalculable. But I bet you we could provide free education for everyone in the USA if we would just introduce single payer. That is why it's such a tragedy. Money that we could use to properly educate our children is eaten up by layers and layers of administration within healthcare.

No, in other countries this never happens with health care.

For anyone else ever in a situation like this - your first step should always be to call the insurance company and the doctor's office if you're confused by or disagree with a charge. Often times it's a simple and very easy to correct mistake on one side or the other.

"To be fair, this is just the same BS red tape you find anywhere. If it were the government instead you'd just be going through the same thing with the government instead of insurance"

No. Heres what happened with my kids births. Wife went into labour, we went to the hospital, had baby delivered, went home with baby. No bills, no insurance problems, not a single form was filled out. The only thing we needed to worry about was making sure we were in for the daily checks given by a midwife at our home.

The US medical system is a trainwreck.

Canadian here. When I go to the doctor or hospital, I give them my name and that's it.

I don't know how Americans put up with the crazy fucked up system you have.

Oddly enough, the codes for each disorder are wildly different between the two systems in an attempt to make sure they don't get them confused and use the wrong one.

What a great country we live in. That you have to pass on a potentially lifesaving test because your insurance might choose not to cover it and stick you with the bill. Makes me fucking furious.

The thing is, the doctor's office generally doesn't want to bill the patient if they can get money out of the insurance company. If they end up billing some huge amount to the patient, odds are the patient won't pay any of it (because they often can't), and the doctor ends up just writing off whatever they billed.

I agree the system sucks, but health care providers generally want the insurer to cover the bill just as much as the patient does.

But what's my copay?

For children, the parents have to sign the consent forms. Maybe the lowest would be sick parents with sick children?

It looks like it was the provider who submitted the claim wrong. Not much the insurance company can do about it until a corrected claim is submitted.

As is the case in 90% of posts in that sub- all it takes is a fuckin phone call.