Amazing! I'm praising Regence BlueCross of Oregon.

This is quite a day.

After a string of highly negative blog posts about what a crappy excuse for a health insurance provider Regence BlueCross Blueshield of Oregon is (see here, here, here, here, here, here, here, here, and here), I've got something good to say about the company.

Today I learned that Regence is going to pay 80% of the cost of the colonoscopy that I had in February, a big jump from the 0% my Regence Evolve Plus plan originally was going to pay.

I complained about this absurdity in "Health insurance companies discourage colon cancer screening."

The procedure went fine. It was even enjoyable, in a drugged-up sense. A flat polyp was found and removed in the first colonoscopy's "bad prep" area. Once again, it turned out to be benign.

This is the good news. The bad news arrived in the mail a few days ago: an "Explanation of Benefits" form from Regence of Oregon regarding my colonoscopy. Total Regence Paid was shown in bold at the top.

The amount: $0.00

Total Member Responsibility to Provider(s) was right next to it. The amount: $805.69

...Perplexed, I phoned Gastroenterology Specialists of Oregon and talked with their insurance company billing person. She told me that because a polyp was removed, Regence considered the entire colonoscopy a "medical procedure," not a preventive screening.

...the billing person told me that every private insurance company she deals with considers that removing a polyp stops a colonoscopy from being a covered preventive service, even though the patient (like me) has no symptoms of colon cancer and the polyp removal is purely preventive, not curative.

Later I got another bill from the physician who did the procedure. That added $938 to my colonoscopy tab, of which Regence again paid nothing (I have a $2,500 deductible).

I was all set to appeal, since preventive services are supposed to be fully covered by Regence's Evolve plans, and I could provide quite a bit of evidence showing that removal of a benign polyp is an integral aspect of a preventive colonoscopy.

When I phoned Regence customer service to get some information needed for an appeal, the person I talked to said "I need to talk with a supervisor" after I asked why Regence didn't pay for my colonoscopy even though the primary diagnosis code was for a screening procedure.

Coming back on the line, she told me that my provider had submitted an adjusted claim and that I'd likely be a lot happier after it was processed.

While we were on vacation the Portland Oregonian ran a story that casts light on Regence's change of heart about paying for colonoscopies where a polyp is found and removed. Browsing through saved papers upon our return, I was encouraged to come across "Colonoscopy coverage creates confusion."

Because near the end of the piece I read:

In addition to Kaiser Permanente and Health Net, Regence BlueCross BlueShield, which has 3 million enrollees in four Northwest states, initially said it charged members the deductible and coinsurance if a colonoscopy found and removed a polyp. But Regence spokeswoman Rachelle Cunningham subsequently said that was a mistake, there should be no cost-sharing charges, and the company was "re-evaluating and re-processing some claims."

She also said patients "might need to take an active role in appealing a claim they felt was processed incorrectly to receive the benefits they are entitled to under the law."

I'd been checking my Regence account online almost every day the past few weeks, figuring that the adjusted claim should be processed soon. This morning I saw that Regence was paying $644.55 for the facility part of the bill, and $750.40 for the physician part.

Leaving me with 20% co-insurance. I'm not going to quibble about that, since a flawed prep and removal of a benign polyp during my colonoscopy two years ago meant that I had a repeat procedure much sooner than if I'd had a normal "all clear" colonoscopy.

So kudos to Regence BlueCross BlueShield of Oregon for deciding, albeit belatedly, that colonoscopies should be considered preventive even if a polyp is removed. This makes me feel better about the company my wife and I fork over $1024 to every month for our individual policies (we're in our early sixties and can't wait to get on Medicare).

That said, I still think Regence's proposed 2011 22% rate increase is obscene.

Today a couple of Regence guys met with the Salem Statesman Journal editorial board. They did their best to justify their rate increase, but I wasn't wildly impressed with the 20 minutes of the video that I watched.

The presentation started off with an oft-repeated statement that the 22% translates into an average of $36 per month for each individual policy holder. Well, not for people like us, who already are paying over $1,000 a month (as a couple) and would fork over more than $200 a month additional to Regence if the rate increase is approved as is.

I realize that the causes of health care inflation are various and widespread. But the Regence executive correctly told the editorial board that the United States health system (actually, non-system) is broken. Costs can't be controlled until we fix the system.

Yet Regence, along with the rest of the insurance industry, tried to stop Obama's health care reform efforts, a.k.a. the Affordable Care Act. You can't have it both ways, Regence. Don't complain that the system is broken at the same time you're trying to keep it that way.

For that huge bit of hypocrisy, I think you deserve to have your rate increase request slashed substantially by the state. Maybe then you'll be motivated to reform the system, rather than simply trying to suck more premium dollars out of your already-strapped policy holders.

Comments

[RM3 Frisker]

Health insurance companies raised their rates obscenely because this was like the last year they could do so before Obamacare fully kicked in. Had Obamacare not been inflicted upon us, insurance rates would have just risen with inflation.

[Blogger Brian]

Not true. Our Regence premium has been going up by double digits every year for a long time. The most recent increase has very little to do with health care reform.

We approve of the "Obamacare" changes -- better coverage for preventive services, for example. It's the very high administrative costs of private insurance, compared to a well run government plan like Medicare, that is one big driver of excessive insurance costs.

Similarly, see if UPS will deliver a letter for you if you pay them 44 cents. Then take that letter to the post office and see what happens.

[Also an Oregonian]

Found your article while googling after discovering for myself the Catch-22 of the so-called "free" colonoscopy screening required by the "Affordable" Health Care law. A Lifewise of Oregon rep. told me that even polyp removal and biopsies would be covered 100% (no copay, no deductible) as long as the provider codes it as preventive. So I called the billing dept. of my local (also Oregon) gastroenterologist who informed me that not only must they code it as diagnositic if they find a polyp, but if they find ANYTHING, even a hemorhoid or diverticulitis. WTF! I told them Lifewise said it's completely up to the provider as to whether or not they code it as preventive, but she insisted they must sticke with AMA guidelines to stay legal. I don't think your thanks should be going to Regence but to your provider for, as you said: "...she told me that my provider had submitted an adjusted claim." What a disgusting situation for health consumers in the US.

[Kate]

My husband just had a second colonoscopy at Vancouver Clinic and I was slated to have my first...until we got the bill for $2600. To say we were shocked is an understatement since the nurse in his pre-op meeting said his second one would be covered 100% by our insurance..and she knew his first one involved polyp removal. The explanation from Vancouver Clinic was someone there 'should have' entered it in the computer in such a way that we 'should have' been notified before the procedure that we would be responsible for all costs because his first colonoscopy involved polyp removal. Obviously, we were not notified and a discussion with an office supervisor hasn't resulted in any adjustments to the bill. We'll find out how to appeal and hopefully that results in a bill adjustment.

As to how they code it.. I was told by someone at Oregon Clinic that once the doctors complete the records they are sent to an independent "coding" group, presumably to avoid coding fraud. When I suggested I'd want a preauthorization from my insurance company BEFORE I have my colonoscopy to ensure coverage, she said unless preauthorization is REQUIRED by my insurance company, they cannot do it. She said even if it is required, it is not a guarantee of coverage. She did say I could request a 'predetermination' before the procedure and that would bind the insurance company re: coverage amounts.

btw, the issue of no insurance coverage for preexisting conditions also applies to mammograms. I hope the person who made the comment "...after the Affordable Care Act is fully implemented in 2014, the preexisting condition coverage issue will be eliminated" is correct..

[Brian Hines]

Kate, sorry to hear about your husband's similar problem. This shows why the Affordable Care Act is needed so badly. Hopefully the Supreme Court won't declare it unconstitutional, or at least allow the pre-existing condition clause to remain.

But it'll be difficult to do away with the pre-existing condition clause unless everybody is insured. That's why the mandate is essential, and was a Republican priority until health care became unduly politicized.

Keep fighting. I was successful in getting my colonoscopy covered after rebilling by my provider. Hope you're as fortunate.

[Lynda - Aurora, IL]

Not only happening in your neck of the woods...I have had the same EXACT experience just recently and my insurance company HumanaOne, Illinois, is telling me that they only bill based on the coding sent through by the provider and the provider is telling me that due to a polyp being removed the billing is sent through based on the results of the colonoscopy, not the original reason (preventative screening) I was having the colonoscopy...I even spoke to the "coding" department and they went as far as to tell me that it would be "medical fraud" for them to change the coding and re-submit my bill (even though the original code was for preventative)! I guess that's supposed the scare me to just back off and pay the bill. I'm more determined now than ever as I even re-applied (full physical and increased premium) to HumanaOne 1/1/12 as my original policy was grandfathered and did not include the Preventative Care. I've been dealing with this since March and have not been able to accomplish anything to date...Not giving up yet.

[Teri Haus]

This has all been very enlightening - I had a 'preventive screening' colonoscopy last summer and still am fighting the $3000 bill - and no one has yet explained to me, not the provider nor the insurance company, that perhaps because a polyp was removed - that is why I am not being covered at 100% and only my large deductible was applied. Wow - no one could actually say this to me after how long I have struggled with this bill. I am perplexed that a GI center would not have explained this possibility to me before having the procedure since they are the ones who recommended I have the test and should have come across this issue before me. And, the doctor told me it would be paid because even though I was 49 at the time, I fell under the 'high risk' category. So, the uninformed patient/consumer is just left holding the bag even though all the info within a reasonable reach indicated to that consumer (me in this case) that the colonoscopy would be covered in full. Plus, the insurance handbook supported what the doctor said - how could one ever have known this would happen. It sounds like bate and switch for sure. There has got to be some way out of this.

[Ken Baker]

I just had my second colonoscopy and got a $3200 to go with it. Had one 5yrs ago with polup removal so now its considered diagnostic instead of preventable, really!!! My polocy states preventable is 100% covered and uses colonoscopy as an example. No where does it state only if its your first or any type of conditions. I think this is completely out of line and someone needs to do something!!!!
Please let me know if anyone has any ideas

[Rick Warren]

I am dealing with a similar situation, also with Regence. I'm already on my second appeal with Regence and this time I'm going to go to the Oregon Division of Insurance Consumer Advocacy Unit (maybe they'll be less biased then the "appeals" board INSIDE Regence).

It sounds like there are enough cases of this happening for a class action lawsuit.

[Drops of Jupiter]

Found my way here in 2015 while researching whether "providers" can refuse to code an ACA-recommended preventive service as preventive. Several years after this blog post was written, nothing has gotten any better. In fact, I'd say it's gotten worse. Up until this past year, if my "provider" tried to bill a preventive service as medical, I got in touch with my insurance company and let them hash it out until the "provider" changed it. Now my "provider" refuses to change the code, and my insurance has started saying there's nothing they can do about it. For those asking what we, the patients, can do to fight this bogus system? Support single-payer healthcare like the rest of the modern world does. That's the only thing that will stop the shakedown.