Insurance Claims - who decides?

[twainny]

Anyone know who decides if a medical procedure will be covered by insurance? I am going to have two moles removed, and the doctor says that they are not cancerous, so the removal would be cosmetic (even though both are not visible.) But she did say, that if I don't take care of them that they could become cancerous. Anyways, she said insurance won't cover the removal. I am thinking of calling the insurance company to see what they say.

Can I ask the doctor's office to bill the insurance company and see if they will cover the procedures? (of course the doctor won't remove both at the same visit *sigh*).

Anyone know?

[jennylou]

The insurance company decides. It depends upon your policy.

But, it also depends upon how the Dr bills. It could be that the Dr's office prefers for patients to pay, because then they don't have to hassle with insurance companies and negotiated prices.

I'd call your insurance company and ask them if moles that are suspicious looking are covered under your insurance policy in regards to removal. If they are, the Dr should be willing to bill the insurance company directly.

[NicoleWisconsin]

I'm not sure how medical works, but I work in a dental office and we can pre-authorize visits - say what needs to be done and how much it will be... then the insurance company sends back whether they will cover and how much. Maybe you could ask about that?

[sixlets]

Your insurance company decides on what is covered and what is it not based on your individual policy with them.

Call your insurance company directly and ask what their policy is. There are codes that are used to show the insurance company what procedure you had done, and there are codes that are used to show the doctor's diagnosis. I would hope that your doctor doesn't flat out state that it was cosmetic. The procedural codes would just show them you had them removed-it would be the diagnosis codes that came into question.

As already mentioned, if the doctor thinks there will be an issue with payment, get the prior-authorization done. It will take some time and a bit of work on the office's part, but it will save you from having to pay in the long run, and it will get their money quicker.

If you have any more questions, please feel free to ask-I am a claims processing specialist at a billing company.;)

[twainny]

Thanks everyone. I will call the insurance company.

sixlets - I may PM you. :) thanks!