Blood work billing - Wrong codes

[noelm]

Hello folks,

I went for my annual physical last year in the first week of July (2012). My PCP ordered some bloodwork. Now after a little more than one year I get the bill. Snowflake details follow.

The claim for the bloodwork was sent to the insurance company quickly after the work was done. The insurance was swift at their work and denied the claim. The reason for denial was, wrong billing codes.
I talked to the insurance company and explained the case. She concluded that the billing codes were wrong and an appeal was possible within 45 days with the correct billing codes. But since it is past that period, an appeal will be most likely denied.

So somebody at the doctor's office or the lab made the mistake. I wonder, how should I handle this?
or, just suck it up and pay $350 for regular blood work?

Thanks in advance.
(Bonus question - Is there any way to complain about this delayed billing and get somewhere with it?)

[Htown Harry]

I'm confused.

More dates are needed to develop an opinion. What was the duration between the denial in August 2012 and your conversation with the insurance company? What was happening during that time?

Based on the information provided, I'm leaning toward the party who didn't act timely having the responsibility to pay the bill.

[ratto]

This happened to me once as well. The good news is that the insurance claim was approved. The bad news is that the wrong test was ordered and performed so that I had to have the blood drawn for the 2nd time. The bright side is that I didn't have to fast, nor was this some internal organ surgery/limb removal operation. After this experience, I always make a copy of doctor's prescription before going to the hospital.

[utrecht]

Ive had this happen twice. The first time it was just like you. The doctors office waited so long that some deadline passed and the insurance company denied the claim. I told the doctor's office it was their fault that they were incompetent and I wasn't paying. Eventually they wrote it off.

The second time just happened a week or two ago and I dont know the result yet. The insurance company said they would take care of it, but I suspect I will hear about it again when someone drops the ball.

[MichaelB]

Even a year later, service providers deserve to be reimbursed. If the contract with the insurance company requires they submit bills in a timely manner, their delay should not become your liability. The key here is to determine what you would have owed had this been processed correctly.

I would ask the service provider to resubmit the bill with the correct codes. If the insurer refuses to cover this, they should at least indicate how much they would have covered and what your copay would have been. You can write the Doctor or lab and offer to pay that amount. If the Doctor's office insists on the entire amount, I would complain in writing to the State Attorney General and copy the Doctor.

[Gatordoc50]

You didn't state if the bill was from the lab or the doctor.

[ERhoosier]

Quote:

Originally Posted by Gatordoc50 You didn't state if the bill was from the lab or the doctor.

Seems to me like the liability should rest with whomever screwed up the coding. Also- check the financial liability statement you signed at the provider's office. Many state that the provider will at least assist with proper documentation for your insurance claim- since the insurance will only pay with adequate documentation from the provider and NOT your word alone. I have heard of many folks who got the provider (lab, hospital, doc, whatever) to take care of the bill when it was demonstrated that it was their office who messed up the insurance filing.

Good luck & keep at it!

[Silver]

The insurance company telling you the billing codes are wrong only means "we don't pay for these billing codes". It doesn't mean the tests were coded incorrectly.

If your insurance covers general annual screening labs but you have a diagnosis that a lab test was ordered for, it may be coded with that diagnosis rather than screening. Examples include anemia, and a CBC with H&H ordered. Diabetes type II and blood sugar and A1C ordered. High Cho and cho panel ordered. If this falls under a deductable rather than an annual "free" testing, the charges would apply.

It most often goes back to how the physician ordered the testing and the codes they use, which most often are specific diagnosis related rather than "screening". That could be challenging to get the physician to change how they ordered something.

[infoseeker]

In 2011 ago my husband went in for his annual physical and screening labs. Labs were 100% paid by the insurance because they were coded as screening. Results of the 2011 screening lipids panel indicated high cholesterol and the doc put him on a prescription med. In 2012 he again went in for his annual physical and screening labs. This time, however, he had to pay for the lipid panel becuase the office coded it as a diagnostic test. Their explaination was that since he was now being treated for elevated cholesterol the annual lipid panel could no longer be coded as screening.

As we age, we will most likely develop some medical problems which means all the associated screening labs (free)will turn into diagnostic labs (not free) Why then is the annual physical itself still coded as screening and not diagnostic? I dont understand why labs turn into diagnostic, but not the physical exam....

[MRG]

I've always taken the stance that these issues are between the provider and payer. So far one of them has always coughed up(or written off) the charges.

I probably should reconsider this as technically , I'm responsible. Oh the pain, I'm still trying to get my wifes medicare to realize she's not covered under Megacorp anymore. That's been going on for 3 months now!

MRG

[Gatordoc50]

The problem was that the denial wasn't addressed timely. The claim probably sat in a denial pile waiting for the doc to correct. Many of these denials require hours of work to substantiate claims. About 5 % of claims are denied for some reason or another. We kept track of the biggest deniers of claims and eventually stopped accepting those insurers.

[travelover]

This has happened to me twice. First time lab tests were coded wrong, second time, insurance company admitted fault. Persist, it is a free for all with no transparency.

[noelm]

Quote:

Originally Posted by Htown Harry More dates are needed to develop an opinion. What was the duration between the denial in August 2012 and your conversation with the insurance company? What was happening during that time? Based on the information provided, I'm leaning toward the party who didn't act timely having the responsibility to pay the bill.

Labs ordered and performed - 07/16/2012
Insurance denial - Sometimes in August 2012
Bill received - 07/23/2013

What happened between 08/2012 and 07/18/2013 (when the bill was made), I don't know. I tried to reach them yesterday but could not reach.

What I told the insurance company about the case and what billing codes were sent did not match. Hence, they informed me that the wrong billing codes were used. Timely appeal could have fixed the issue and then I would have owed nothing. And now I owe about $350.

Nothing was diagnosed during these screenings.


@GatorDoc50,
My doc works in the hospital (i.e. his practice is located in the hospital) and he uses hospital facilities for many things, like the labs. So the labs bill was sent by the hospital and not the doc. So I am not too sure how the doctor will be involved in this. If I understood correctly, once he ordered the tests, he is done, right?


@MichaelB,
Everytime, we the users, have time limitations in everything, like paying the bill (else it goes to collection), depositing the check (or it goes void) then should the same be with the providers as well? If the claim was denied, why the bill wasn't sent to me right away? Why did it take about 10 months to send the bill?
If I legitimately owe the bill, I WILL pay because I am not a big shot that can hang them in a public square. I am just a regular Joe but why the rules are ONLY for me and not for them?

Honestly I have never seen such fcuked up healthcare anywhere in the world and there is absolutely no will to fix it.

[grasshopper]

BCBS will not cover my labs, unless LabCorp, or Sonora Quest does them. So I have to leave my Drs office and drive an hour one way instead of having it done in-house.

[noelm]

OK, So I talked to the hospital and as I expected, she was extremely assertive. She mentions that I recd. EOB (which I don't find) and it is my fault that I did not appeal to the insurance company.

AND

THEY HAVE 7 YEARS to send out the bill and I am like, WTF?
So no answer to, why the bill was sent out late.

Seriously, Why should I like either of these institutions? So much of imbalance of power.

[Silver]

Quote:

Originally Posted by noelm Labs ordered and performed - 07/16/2012 Insurance denial - Sometimes in August 2012 Bill received - 07/23/2013 What happened between 08/2012 and 07/18/2013 (when the bill was made), I don't know. I tried to reach them yesterday but could not reach. What I told the insurance company about the case and what billing codes were sent did not match. Hence, they informed me that the wrong billing codes were used. Timely appeal could have fixed the issue and then I would have owed nothing. And now I owe about $350. Nothing was diagnosed during these screenings. @GatorDoc50, My doc works in the hospital (i.e. his practice is located in the hospital) and he uses hospital facilities for many things, like the labs. So the labs bill was sent by the hospital and not the doc. So I am not too sure how the doctor will be involved in this. If I understood correctly, once he ordered the tests, he is done, right?

I think both GatorDoc50 and I already explained what most probably happened.

Your insurance denied the charges probably because they were not coded as "screening" but with an ICD-9 code that is diagnostic. Doesn't matter that nothing was diagnosed that visit. The code used is whatever ICD-9 the physician believes fits at the time they are ordering the tests.

You should have gotten an Estimate of Billing (EOB) within 4-6 weeks after the charges. When the lab got the denial of payment from your insurance they sent it directly to the physician to re-code because they want to be paid. As GatorDoc50 said, it probably sat in a stack of denials on the physician's desk (or someone's desk in the physician office) for a year because they take time to track back and try and fix, and no one wants to deal with them. In his/her practice, they stopped accepting patients with some insurance plans if the plans like to deny charges often. It's just not worth it.

The codes used originally were correct, but not what the insurance company wants to pay for. If it were me, I would ask to speak to the physician's practice manager, explain what happened and ask them to work with you to resolve it.

[meierlde]

Quote:

Originally Posted by noelm OK, So I talked to the hospital and as I expected, she was extremely assertive. She mentions that I recd. EOB (which I don't find) and it is my fault that I did not appeal to the insurance company. AND THEY HAVE 7 YEARS to send out the bill and I am like, WTF? So no answer to, why the bill was sent out late. Seriously, Why should I like either of these institutions? So much of imbalance of power.

Check your states statute of limitations on debts. Typically that is 4 years but it does depend on the state. If they try to send a bill after the statute has hit, just say, that the statute of limitations on the debt has expired, so they are out of luck.

[noelm]

@Silver,
Probably you are right and thanks for the advice. I just talked to the doctor's office. Lets see how it goes now.

With the EOB, I do not find it in my file so probably, I did not get it (because I am OCD about filing properly) and I can not access it on their website either (rest all EOBs are accessible).

Quote:

Originally Posted by meierlde Check your states statute of limitations on debts. Typically that is 4 years but it does depend on the state. If they try to send a bill after the statute has hit, just say, that the statute of limitations on the debt has expired, so they are out of luck.

Its 6 years in NY but it did not occur to me, thanks for reminding me.

[Gatordoc50]

So the doctor or lab gets only 45 days to submit a bill for payment to the insurance company but gets 7 years to bill the patient. Hmmmmm. That should clear up who's in charge here and has the strongest lobbyists in Washington.

[noelm]

Quote:

Originally Posted by Gatordoc50 So the doctor or lab gets only 45 days to submit a bill for payment to the insurance company but gets 7 years to bill the patient. Hmmmmm. That should clear up who's in charge here and has the strongest lobbyists in Washington.

EXACTLY, if you are the doctor then you should also check out with AMA about their lobbying in Washington.

Offnote, I read an article about somebody in Washington that signed/supported the bill that patient can not sue the doctor for xyz. After 10 or so years, he wanted to sue the doctor for the same XYZ that happened with him. It turned out that he can not because the bill that he signed/supported.
I burst into laughter after that. so glad that S0B suffered what others suffer on day-to-day basis.