Ultrasound OperatorMuch like any other insurance issue, coverage for ultrasounds depends on the terms and conditions stipulated under your individual or group policy. It is important that you talk to your health insurance provider before scheduling an ultrasound so as to avoid unpleasant billing surprises later.

Since there are different kinds of ultrasounds, health insurance companies are likely to have different kinds of rules to determine coverage. Make sure you understand the exclusions that your health insurance policy has in place to avoid any unnecessary and time-consuming ordeal as you grapple with unexpected and expensive payments.

In cases that require ultrasounds, doctors and insurance companies can have very different philosophies, which lead to between 10% and 15% of claims being denied. So head to your computer, health insurance advisor, or HR person dealing with insurance matters in your company to get some clarity. After all, an informed consumer is the best advocate.

What is an ultrasound?

An ultrasound scan utilizes high frequency sound waves to create an image of an internal organ. Also called a sonogram, these scans are used to detect disease or abnormalities in organs. They are also used during surgical procedures. Obstetric sonography or ultrasound is used to check the health and growth statistics of a fetus.

Ultrasounds vary in type. They can produce two-dimensional, three-dimensional, or Doppler images. While 2-D imaging is most commonly used, 3-D imaging is largely being encouraged in cases of early detection of cancer as well as abnormal development of limbs and faces in fetuses. Doppler imaging is used to measure the rate of blood flow.

Ultrasound scans are faster than radiographic procedures such as X-rays and allow the observation of certain organs without the use of radiation.

Why do health insurance companies deny coverage for ultrasounds?

Health insurance companies have stringent rules and regulations in place that determine coverage or lack thereof. However, claim denials can occur because of mistakes. So make sure you cover all your bases and know your rights under your individual or group insurance plan.

Health insurance companies can deny coverage because of a number of reasons. In some cases, denial might occur because the doctor and the insurance company have different treatment philosophies. So it might work to your advantage to get clarification and even pre-authorization, if possible.

One of the main reasons for denial of coverage could be the presence of a pre-condition that now requires an ultrasound scan. While matters of pre-condition have been addressed under the Patient Protection and Affordable Care Act, there is plenty of confusion about its application.

Surprisingly, pregnancy used to be considered a “pre-condition.” While this is required to change by 2014, you should still make sure you are covered for standard or high-risk ultrasounds, if required at the present time.

Health insurance companies also deny ultrasounds that they deem experimental. This could be an advanced level avatar of an old procedure or a completely new procedure that your doctor advises you to get. So talk to your insurance provider and get clearance for the procedure.

Another factor for denial is the lack of medical necessity for a sonogram. Health insurance companies routinely deny coverage for any procedure they deem medically unnecessary. For instance, newly emergent 4-D imaging for fetuses is regularly denied. If you are pregnant, you might want to get a schedule of all allowed procedures dealing with childbirth. This will help you figure out all the coverage terms and conditions.

Do I have any recourse for denied coverage for my ultrasound?

Every health insurance company has processes in place to help consumers file appeals against denied claims. Be aware that these processes can be time-consuming, fraught with frustration, and, in many cases, unhelpful.

If you are unhappy with your denial and think it is a mistake, you need to start the redress procedure by talking to your doctor, claims adjuster, and the benefits manager in your office. Get a clear and detailed explanation of what procedure was performed and why it was necessary. Make sure you get everything in writing.

Before having a conversation with your health insurance company, prepare yourself with some research. Make sure you know why the procedure was required, among other details.

Ask your insurance company to give its reasons for denial in writing. Once you have exhausted the avenue of reaching an agreement through conversations with your doctor and insurance company, your next step would be to file an appeal to fight the decision.

If the appeal against denial of coverage with the health insurance company were rejected, your next step would be to take the issue to the state insurance office. If this department that oversees all insurance matters for your state turns down your request for coverage, then you will be required to pay the ultrasound bill.

Unless it is an emergency, the easiest way to either avoid this mess or prepare yourself is to seek clarification and pre-authorization from your health insurance company.