Ultrasounds during pregnancy and insurance?

ItsGreen · November 2014

So one would think that ultrasounds fall under the 100% Maternity Coverage of my insurance (and obamacare).

However, I got a bill today for my Level 1 Ultrasound, as recommended/prescribed by my OBGYN, especially since I am 35; will be 36 when the baby is born. The Insurance company says because it was done at a "hospital" facility its not covered. Supposedly if it was done at an "imaging center" or "office", it would have. Technically the ultrasound was done at an an office but the office it part of the hospital and a hospital facility. The hospital won't change the coding either.

I think its crazy to have to pay $200 per ultrasound. (the insurance company paid less that half of the charges).

I am scheduled for my Level 2 Ultrasound so I am freaking out a little. There has to be away around this and/or to appeal.

Anybody have any experience with this?

jennypolkadots · November 2014

I would have your doctor's office write a letter explaining that they do ultrasounds in an office that happens to be part of the hospital. This should clear up the billing code issue. Then you file an appeal with your insurance. The issue for them is it was out of network so they didn't get a discounted service rate that they had to pay. You may end up having to pay it in the end, but it is worth an appeal.

I know hind sight is 20-20 but it's your responsibility to make sure that the facility is covered. All insurances have weird nuances like this and most are picky with billing codes. You likely could have just had the scan done at a different facility and it would have been covered 100%. You have to ask in advance though and stay on top of it.

Now that you know this, you need to talk to your doctor's office about the issue before your next scan. Usually they have someone on staff that works just with billing. I'm sure you aren't the first one that this happened to and they should be able to offer some advice. Then you need to consider using another in-network provider that has in-house ultrasound equipment (not connected to a hospital) to perform any future scans. They can send all scan results to your OB so you can stay with the same practice and just have the scans done elsewhere.

itsmevkb · November 2014

When my daughter needed physical therapy our pedi recommended a great place just a few blocks away. I got the bill for the initial consult and whoa! It was a hospital co-pay ($150 for us) so I called and found out it would be the same for every visit since the clinic was actually in the hospital. As a result, we decided to switch to a free standing clinic.

I would suggest you ask your doctor where else you can go to have your scans done and/or call your insurance and find out if there is some form you can fill out for an exception.

allurah2014 · November 2014

Having maternity coverage does not equal everything being free. It still depends on what your insurance does cover (70/30, 80/20) and you are responsible for the difference.

chelc32188 · November 2014

My first ultrasound was WAY more expensive because I hadn't met my yearly deductible yet - so it was only covered at 50%, and I was a little surprised as well - but after sitting down and reading through all of that stuff it all makes sense. I also spoke with the woman at the office who deals exclusively with billing and insurance and she even filled me in on little things I didn't know! That may be useful

GingerMommy315 · November 2014

I keep pretty on top of my insurance coverage, I am able to look at what has been paid out everyday online. My first dating ultrasound was billed to my insurance at $200 which I was billed 20% of. My next two (N/T and Anatomy) were each billed at over $1000 to my insurance, again I pay 20% (so my portion was more than $200 each time).

I would definitely get this straight with your insurance before going in for another one. If they don't cover the location where you have been going, you could be stuck with a hefty bill.

I'm 20 weeks and I have paid out of pocket about $1500 already even with PPO insurance. These babies are expensive!

vpine · November 2014

I have insurance and paying $250 each ultrasound because of the hospital I chose where Ob is at. I called insurance and discussed this, looks like hospital charges their fee plus the tech fee and they have a contracted rate so I have to pay $250 each time.

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