What I learned today about Medical Clinical Policy Bulletins

As I wrote in the last post, today my GI ordered two blood tests to find out if I have genes most commonly found in people with celiac disease. Those two genes are called HLA DQ2 and HLA DQ8.

Since we've had problems in the past with excellent doctors prescribing exams and tests that our insurance company has later refused to cover, I decided to do my homework before going to the lab for the blood draw.

First I called my insurance company to ask if they would cover the test. The representative asked me for a CPT code. As I was still at my GI's office, I asked around and the secretaries and nurse tried hard to find out what it was for me. They referred me at last to client services for the hospital (billing).

Client services tried for over two hours to find out the CPT code and even "googled" it for me but had no luck. They recommended that I call the customer service department for the lab. Which I did. And fantastically, the man answering the phone knew exactly what I was talking about and gave me the CPT code for the bloodwork within minutes.

So I called back to my insurance company armed with the correct code for the procedure and this is what I learned.

Insurance companies issue clinical policy bulletins to physicians which detail research in the field related to the diagnosis, and then give directives about the "correct" route to diagnosis that will commonly yield the most positive results for the least amount of money.

Our insurance company has a website and on it there is a whole section for health providers. Your doctor can enter in several quick codes and it will bring up a wealth of medical clinical policy bulletins, detailing the insurance company's determination of "best practice".

If your doctor follows the insurance company guidelines, the procedure or medicine will be covered at your selected level of benefits. (For our family, this means 80% after we reach our annual deductible, and then 100% after we reach our co-insurance maximum.)

If your doctor chooses a procedure or medicine that he/she believes is best practice but the insurance company does not agree, your insurance company will tell you that the procedure selected is "experimental or investigational" and that neither you nor they are required to pay for it. Unless of course, you have signed a paper that says you will pay whatever insurance doesn't cover. (Which of course, every doctor's office has you sign before you even get to see the doctor or describe your symptoms...) So in the end, you as the patient are stuck with the full bill... which is not even adjusted down by your insurance company.

If you find yourself in this situation, where you've been given some test, procedure or medicine that your insurance company refuses to cover - best thing to do in my opinion is contact the office of the billing physician and find out if you can negotiate a cash price or payment plan. A lot of the time they would rather get less cash right away than spend years trying to get the full amount from you through collections agencies.

The takeaway message here is that it might be a good idea to go online to your insurance company website to find out what their medical clinical policy is about your particular situation.

For my situation, I discovered that my insurance company views both the genetic blood test ordered by my doctor AND the endoscopic procedure he discussed (wherein you swallow a vitamin sized camera that then takes pictures of your gut) as being experimental and without enough evidence to support their use. So, they are basically going to deny any services he has in mind for me.

My husband and I agreed that we would rather spend $200 for the 8 blood tests at $25 a pop to find out if I have the genes for celiac (95% accuracy) out of pocket than end up with an even more expensive endoscopy that the insurance company also won't cover. So, we're going with the blood work and I will keep everyone posted about the results.

This is what I know as of today.

I'll let you know what I learn tomorrow.