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This may seems like a far-fetched conspiracy theory, but this has happened to me twice now… Scenario goes like this: My insurance policy covers X but not Y (or X has a lower deductible than Y). I get healthcare services provided to me for X. Eventually the bill comes in and it is considered a Y service due to the CPT codes assigned and therefore not covered or covered under a higher deductible. This has happened to me in three obvious cases:
The first case and the other cases are actually with two different insurance companies. In the first case it was actually billed and paid as covered, then 6 months later we got a revised EOB stating it was not covered. I concluded that the service code must have been changed but I was unable to prove this since I never saw the original bill and the hospital wouldn’t produce it for me.
The second/third case I just found out about today. We have a maternity specific deductible that is high, but still half of what our general deductible is. By Splitting up all of the services among the maternity/general deductible we are not meeting either one and are therefore paying 100% of the bill.
My theory and question: Is it possible that the insurance adjusters are contacting the providers to get the services coded in such a way that benefits the insurance company the most by allowing them to mark a bill as not covered or by splitting up between our deductibles? I believe this would be fraud, but would also be very difficult to prove considering I’ve not seen a single itemized bill from the providers, just a total with no explanations.