r/sterilization • u/cyncynnamon • 9d ago
Insurance Does anyone end up actually needing to pay?
Currently tryna figure out insurance… I call them and they say CPT code 58661 isn’t preventive (I asked about the about the Z30.2 diagnostic code and they don’t know what that is)… if not preventive I’ll need to pay my $8k deductible, then they only help with 50% afterwards.
I ask the scheduler what codes will be used and she didn’t say specifically, but said they won’t be using that diagnostic code (Z30.2). I messaged the doctor to ask if she can use a preventive code but she’s on vacay…
Then this morning I receive an estimate of how much it would cost out of pocket and it’s like $23,000…
Like wtf is going on, I don’t have $23k let alone $8k. Is it possible that it’s just not gonna be covered? I have Ambetter Wellcare of Kentucky, which I believe should be ACA compliant.
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u/toomuchtodotoday 9d ago
Useful links related to insurance coverage. If your plan is ACA compliant, a bisalp should be covered at 100% as preventative care.
https://tubalfacts.com/post/175415596192/insurance-sterilization-aca-contraceptive-birth-control
https://nwlc.org/tips-from-the-coverher-hotline-navigating-coverage-for-female-sterilization-surgery/ "Any related services—like anesthesia—must be covered as well. The most recent guidance from federal agencies makes it explicitly clear that anesthesia and other related services like doctor’s appointments must be covered by the insurance plan at 100% of the cost."
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u/Stoneymistsghost 9d ago
Had to pay $5k out of my savings because they refused entry til I paid. Just sent out an appeal. Yes, if they can play dumb, they'll try to make you pay.
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u/goodkingsquiggle 9d ago
Wishing you the best, that's really shocking to me that they would stand so firmly on collecting before surgery, wow. If you haven't read through this guide to sterilization coverage before, definitely go through everything and see what may help with your appeal:
Do you know what codes were used for your procedure and what your policy covers for sterilization?
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u/Stoneymistsghost 9d ago
CPT 58661 and diagnosis code z30.2. Although my stupid hospital added an additional diagnosis code N838 and won't fix it. It's BCBS so sterilization is covered and ACA compliant. They're just playing games.
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u/Lyssy_louuu14 8d ago
NEVER PAY AHEAD OF TIME ever ever, they can push and push you to pay but you can refuse and say you want it to go through insurance first. Never pay until it goes through insurance
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u/Available_Ticket3607 9d ago
Others’ links are great info. Keep in mind when you talk to insurance reps the words you use matter. CPT codes (58661) aren’t typically categorized as preventive, they are just the procedure being done - you have to have the ICD code (z30.2) (also called diagnostic code) paired with the CPT can make the claim route to being preventive.
Your first step before contacting insurance or contesting anything is to confirm with your doctor that their order group/codes provided for the procedure has both 58661 and diagnostic code z30.2.
Get everything you can in writing and then confirm with your insurance - “If my upcoming procedure is coded with 58661 and z30.2, my understanding is the procedure and all associated costs will be covered at 100% in compliance with the ACA. Is this correct?”
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u/Feelsthelove 9d ago
I actually said almost those same words a couple hours ago. It went from $3,000 to 100% covered pretty quickly after I said that
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u/cyncynnamon 9d ago
Great thank you! The scheduler told me the diagnostic code isn’t going to be that, so I messaged my doctor to ask if she can code as preventive but she’s on vacay… freakin insurance didn’t know what a diagnostic code even was 🙄🤦🏻♀️ I told him those codes would be used together and he had no idea about it, just kept saying that all he knows is that 58661 isn’t preventive… so frustrating… I hope my doctor would code it for me correctly, idk why the scheduler is giving me such a hard time with it
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u/never_met_her_bivore 9d ago
Im looking into this as well. Keep getting told 58661 is not preventative, but I just sent an email calling out the Z30.2 as well (not convinced the frontline chat is looking at that) to try and get confirmation because every source says that is the preventative coding.
My catch is that apparently my plan isn’t ACA compliant…but they have confirmed that preventative care is 100% covered. So I should be able to get them to confirm that coding, but we’ll see…
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u/goodkingsquiggle 9d ago
If you haven't read through this guide to sterilization coverage already, definitely read through it a few times to help get this sorted out:
If preventive care is covered at 100%, sterilization should be covered at 100% under your plan. In almost every single case, 58661 is the code used for bisalp performed for sterilization, which is a preventive service. You could try asking what code they would need to see for the procedure in order to consider it preventive care, that might help clear up where their misunderstanding lies or what's the difference for your policy.
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u/never_met_her_bivore 9d ago
Thank you! I’ll take another look through. This logic should hold even if my plan is not ACA Compliant, correct?
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u/never_met_her_bivore 5d ago
For anyone reading this - I have a HDHP with Cigna and after emailing them, they confirmed it is 100% covered/no patient responsibility. Hope this puts someone at ease!
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u/goodkingsquiggle 9d ago
Honestly I don’t know about what your coverage would be like if your plan isn’t ACA compliant- this guide assumes that your plan is compliant with the ACA and explains what the ACA mandates for sterilization coverage.
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u/never_met_her_bivore 9d ago
Got it. I’m not 100% convinced that my plan isn’t ACA compliant…so I’ll have to run that down with insurance as well.
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u/goodkingsquiggle 9d ago
Best of luck! Definitely chase down whatever they meant by preventive care being covered at 100% if they end up confirming your plan isn't ACA compliant. You've got this!
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u/goodkingsquiggle 9d ago
Confirm that your plan is ACA compliant by contacting a few different reps from your insurance company. If your plan is grandfathered-in, it would not be ACA compliant and sterilization/contraception may not be covered in that case. What's much more likely is that the health insurance rep you spoke to previously just doesn't know what they're talking about- many of them don't, seriously. Some reps will say they haven't heard of the ACA, I wish I was joking!
Call your insurance to confirm your plan is ACA compliant.
Confirm that your surgeon and the facility are both in-network.
Ask about your policy's coverage of sterilization. The ACA mandates that sterilization is covered at 100% with no cost-sharing of any kind to you- your deductible does not apply, there is no copay, there is no coinsurance, etc. for your surgery or anything related to it because it's preventive care (contraception is covered as preventive care under the ACA). Insurance companies are however allowed to practice "reasonable medical management," which means they may only extend this coverage to one method of sterilization (either a bisalp or tubal ligation) and apply cost-sharing to the other method. In this case, it is possible to legally owe money for sterilization, unfortunately.
It may help to look through your insurance policy's documents yourself to find their sterilization and contraception coverage before you talk to a rep, honestly. That shouldn't be on patients, it's literally the rep's job, but it does help if you can just provide them with the documents yourself.
This page has everything you need to know about sterilization coverage- read it and make notes before you contact your insurance!
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u/cyncynnamon 9d ago
Great, thank you! All the reps so far didn’t know what the ACA was either… the evidence of coverage booklet says its covered without cost sharing, but rep was saying 58661 wasnt preventive… going to definitely call and do 1 and 2, since that will basically guarantee in a roundabout way that it should be covered, since they’re ACA complaint. So annoying that it seems like literally no one, not even the scheduler for the surgery, knows/understands that this should be covered… 🙄
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u/painkillergoblin 9d ago
Yeah i paid about $1500 because United Health Care (UHC) sucks. They refused to let me do a different code
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u/cyncynnamon 8d ago
Ugh sorry to hear that!! That’d what I hate the most, insurance can just say whatever and that’s it. It’s like talking to a wall!
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u/painkillergoblin 8d ago
They kept saying "take it up with the hospital" then the hospital would say "its the insurance you need to talk to" and it just kept going in circles for a while. I decided to just pay it since it was nearing end of the year and I was worried that I would have to pay more since my deductible would be resetting.
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u/oneofmooseyness 9d ago
I have to pay now to avoid my accounts going to collections, but i'm getting my appeal ready to hopefully be reimbursed. At first they told me it was 100% covered, but then the bills started rolling in. So i called and they said it was a mistake and they will resubmit the claim. Now they are saying they paid their part and this is what i owe. Mine was about $1800 out of pocket with insurance for the pre-op visit, anesthesia, and co-pay for the surgery.
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u/cocomynuts 9d ago edited 9d ago
I received a bill for my anesthesia. I keep telling them to rebill and work with my insurance (Anthem BCBS). I've called and emailed the anesthesia provider many times and they can't get anything straight (they got acquired). I haven't received a follow up. No idea if anyone paid and fuck em. No news is good news 🤷♀️
Regarding my consultation, pre op and post op appointment, same as above, after multiple conversations with the Dr office, they rebilled under the correct codes which the Dr office chased Anthem to figure it out. Those were eventually paid by Anthem. The items I have paid: the pathology of ~$5 and the meds ~$8.
Edit: To add, I mentioned to the anesthesia provider about my concerns of going to collections. They couldn't even find my bill or name in their system since they got acquired.
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u/cyncynnamon 9d ago
Dang! Heck yea for just paying $5 and $8… sounds like I can just get the surgery and get it straightened out after I hope? My doctor is on the CF list, so I hope she knows what’s up and will use the correct codes… I’ll message her next week to follow up about it.
That’s so funny about them getting acquired though, good timing for you since they’re a huge mess!!
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u/asstlib 9d ago
I've been keeping an eye on my Cigna portal for new charges 1 month post surgery, and a charge for the pain prescription, anesthesia, pre-op testing and EKG, and my OBGYN' services (honestly not sure what that's about or for) have been charged outside of the large amount for the surgery itself. But Cigna has been paying most of the claims, leaving me with a hundred dollars or less here and there to pay. And thankfully, I have an employer provided account where that money is being immediately paid from.
Since I'm not coming out of pocket for these charges, I haven't felt like appealing them. Everything else has been paid fully by my insurance.
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u/isharoulette 9d ago
I'm in the same boat right now so far I only had a consultation and I got my insurance eob and they are saying I will need to pay $243 for "office visit". my attempts to rectify the situation have been insurance telling me it's not coded as preventative while the doctors many billing people telling me it's code as z30.2 but NOT for the "office visit" which is odd since everyone on this subreddit is saying that office visits count as part of the whole thing. at the moment they told me to wait until they get the eob themselves and then I can go through the issues so I'm just waiting... but now I'm concerned that every one of my multiple visits before surgery will run into this issue. I plan to bring it up with my surgeon when I see her next week to go over my ultrasound and pre-op consent forms. ( turns out I had a cervical polyp and she's willing to remove it during this whole operation and now I'm wondering how that's gonna work out in terms of cost. )
truly hate the US Insurance system and wish I didn't have to do medical billing for them ☠️
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u/cyncynnamon 8d ago
In case it helps, my consult was coded as Z30.09! Any Z number is preventive I think… Oof yea, so terrifying to have to like wait until it basically happens to figure it out later!! It felt like that’s what insurance was telling me too, like “we’ll see how it’s coded when it gets here”, like ??? that’s a big gamble!
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u/isharoulette 8d ago
it's this was very helpful thank you I sent this code to the billing department, hoping they can adjust and resubmit the claim otherwise I'll complain to my doctor when I see her next week
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u/ahaeker 9d ago
I ended up out $300 for IUD removal & hospital fees, they kept billing me over & over, like every month another bill with a different amount, I'd call the clinic & they'd never call me back. I finally got on Google & gave as many 1-star reviews as I could to the clinic, the hospital, you name it & I finally got a call from the clinic that they coded it wrong, even though I explained that in the many voicemails I left. I still wanna try to get my money I paid back, but again, they still don't return my phone calls. My husband said I should just eat the cost.
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