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ACA requires blood tests? Really?
Old 01-15-2016, 09:53 AM   #1
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ACA requires blood tests? Really?

Ran into something this year and I'm trying to find pointers to the actual requirements.

I take Levothyroxine due to thyroid issues. Have taken it for several years. After the first year, we figured out the dosage and thereafter I have just had my blood test done once per year at my annual checkup. Never been an issue. I did have to call and have the prescription reissued every 6 months but that was just a phone call.

This year 6 months after my checkup, the nurse said I would have to come in for a blood test and doctor visit to have the prescription reissued. She said it was legally required by the ACA. Sort of strange since we had gone years without having to do this. I can find no legal requirement that says they must do a blood test every 6 months.

I did change to BlueCross insurance this year. So I called their help line and after some discussion/hold cycles was told once per year was standard practice and the blood test was covered under my annual physical once per year as a normal "well care" visit.

I really don't want to be teathered to have to come in and have a blood test every 6 months and it seems a waste of time and money for both the doctor and me.

Does anyone have any real info on whether this is legally required? Is the clinic just trying to generate income or somehow reduce their chance of a lawsuit if something goes off the rails?
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Old 01-15-2016, 09:56 AM   #2
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Does anyone have any real info on whether this is legally required? Is the clinic just trying to generate income or somehow reduce their chance of a lawsuit if something goes off the rails?
This is either the insurer or the clinic. Since you spoke with the insurer, it looks like the clinic. The ACA doesn't engage in this type of regulation.

Edit to add - here's a detailed implementation timeline by KFF, you can see all the components of the ACA that affect prescription drugs http://kff.org/interactive/implementation-timeline/
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Old 01-15-2016, 10:22 AM   #3
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Kids say the dog ate my homework. Medical providers say Obamacare made me do it.
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Old 01-15-2016, 10:26 AM   #4
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I'm always amused at the never-ending ways the ACA gets the blame for all sorts of things it has no part in creating.
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Old 01-15-2016, 10:47 AM   #5
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You should ask them to see the requirement. There is none due to the ACA .

It probably depends on the condition, drug involved, Dr preference, clinics practice etc. but many times a visit is required to get a refill/renewal. And I'm sure money and CYA is involved.

Looks like recommended monitoring is 6 - 12 months

When the optimum replacement dose has been attained, clinical (physical examination) and biochemical monitoring may be performed every 6 to 12 months, depending on the clinical situation, and whenever there is a change in the patient's status

Thyroid Hormone (levothyroxine)
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Old 01-15-2016, 10:54 AM   #6
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I am not on ACA, but for years I was required to have lab tests and appointments every six months due to high BP, high cholesterol, and blood sugar meds.

In fact, in December he switched me to an every-three-month schedule for lab tests and appointments because I recently went from pre-diabetic to type 2 diabetes. I am hoping this is temporary, but who knows.

In my case, Medicare Part B plus my insurance pay for all of this, thank goodness.

As an aside, I am SO glad that my favorite video game, Animal Crossing, is available on a portable gaming console that isn't much bigger than my cell phone. So, I can happily sit for an hour or two in his waiting room and play my game in total contentment. I remember back in the "good old days", when waiting rooms were horrendously tedious.
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Old 01-15-2016, 03:00 PM   #7
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I did change to BlueCross insurance this year. So I called their help line and after some discussion/hold cycles was told once per year was standard practice and the blood test was covered under my annual physical once per year as a normal "well care" visit.
They will cover the once per year blood test but you need to make sure your doctor codes the request properly. I just ran into this with BCBS during my annual physical last month. For some reason the doctor coded the blood work as diagnostic and BCBS wouldn't reimburse the cost as part of my annual preventive care. I had to get my doctor to resubmit the blood work request as preventive care.
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Old 01-15-2016, 03:26 PM   #8
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I'm always amused at the never-ending ways the ACA gets the blame for all sorts of things it has no part in creating.
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Travelover: Kids say the dog ate my homework. Medical providers say Obamacare made me do it.
+1

I would speak to my doctor about it.

Perhaps his treatment is based upon an evidence-based medical protocol which I believe ACA is designed to encourage.

I have had behind the desk medical personnel tell me that:

- There is no mandate for insurance companies to provide any preventative care without deductible

- That my insurance company would not pay for blood tests conducted more than one week away from my physical. (they are generalizing based on Medicare rules which are not relevant to my BCBS group employer insurance)

- The doctors don't like it either when blood tests are taken on a different day

All of these were proven to be quite false indeed.

Starting to think that the same concept might apply to many new medical occupations that also apply to Big Box electronics sales people:

"If you breath deep, you might still smell the french fries on them from their last job"

From their perspective, on the other hand, dealing with a "know it all" general public is probably no picnic either.

-gauss
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Old 01-15-2016, 03:38 PM   #9
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W2R, I hate to tell you but the blood sugar thing is not going away. I also deal with the same problem. My fasting numbers are always under 100 but after meals if I eat lots of carbs the numbers jump over 200 and will stay that high unless I walk.
I have been able to handle this for 11 years with diet and exercise but as I age ( 68) I know there will come a time when I need meds.

Its hard to keep up the diet and exercise everyday and some days I say the heck with it. My A1C was 5.5 last August but it takes hard work to keep it that low.

Blood sugar and blood pressure go hand in hand. My blood pressure has recently went up as my blood sugar. Just started another medicine for blood pressure and I don't like the way it make me feel but it has helped keep the number low. My blood sugar this morning was 88 but I walked three miles yesterday and limited my carbs. We can fool those tests but as I said the problem will always be there.

I am now using the VA as they do everything in the blood work. I am required to have tests done every 6 months. I just do it

Good luck on your problem. oldtrig



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I am not on ACA, but for years I was required to have lab tests and appointments every six months due to high BP, high cholesterol, and blood sugar meds.

In fact, in December he switched me to an every-three-month schedule for lab tests and appointments because I recently went from pre-diabetic to type 2 diabetes. I am hoping this is temporary, but who knows.

In my case, Medicare Part B plus my insurance pay for all of this, thank goodness.

As an aside, I am SO glad that my favorite video game, Animal Crossing, is available on a portable gaming console that isn't much bigger than my cell phone. So, I can happily sit for an hour or two in his waiting room and play my game in total contentment. I remember back in the "good old days", when waiting rooms were horrendously tedious.
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Old 01-15-2016, 03:40 PM   #10
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Thanks, Oldtrig. I'll keep working on it, for sure.
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Old 01-15-2016, 08:22 PM   #11
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DW has bloodwork for thyroid every six months. The dosage typically gets adjusted maybe once a year a minute amount. For the past fifteen years. Have had at least six different PCPs in that time frame.

Not part of Obamacare.
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Old 01-16-2016, 04:48 AM   #12
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Spoke with a nurse about the issue and she said it actually came into effect last year and the doctors had pushed off implementation as long as they could. Seems the clinic gets audited by some agency and occasionally the insurers will call to make sure an office visit was actually done before a prescription was renewed. Said they had cases where the prescription claim was denied because they issued over the phone without a visit. Patient had to pay the entire cost of the prescription. I'll talk with the doctor next week about it in more detail. Shame to waste his time and mine with a visit just about billing and how to deal with paperwork rather than having him see patients with health needs. In my case the meds are cheap compared to the office visit and bloodwork.
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Old 01-16-2016, 09:35 AM   #13
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it may be their malpractice insurance may require it.

Ask your doctor to write a script for a year... that would remove the 6 month appointment. Likely doesn't because the guidelines recommend monitoring every 6 months. Blood pressure and cholesterol meds are the same way. There are things that can happen... but I think those are the exception.
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Old 01-16-2016, 09:37 AM   #14
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That may be some insurance company requirement, but it's not related to ACA.
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Old 01-16-2016, 11:06 AM   #15
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They will cover the once per year blood test but you need to make sure your doctor codes the request properly. I just ran into this with BCBS during my annual physical last month. For some reason the doctor coded the blood work as diagnostic and BCBS wouldn't reimburse the cost as part of my annual preventive care. I had to get my doctor to resubmit the blood work request as preventive care.
BCBSNC is pulling that crap on me this year. Not for just my annual well visit, but for my wife's too. I'm just going to do all of the appeals and stuff to chew up tons of their administrative time. It's not much money, but it's the ONLY thing I got from my 2014 policy.

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That may be some insurance company requirement, but it's not related to ACA.
When I saw the thread title, I thought of The Beatles' "Piggies" but the thread didn't go that way, thankfully; nothing to do with ACA.
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Old 01-16-2016, 11:59 AM   #16
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Kids say the dog ate my homework. Medical providers say Obamacare made me do it.
This. ^^


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I'm always amused at the never-ending ways the ACA gets the blame for all sorts of things it has no part in creating.
Very much this. ^^
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Old 01-16-2016, 01:38 PM   #17
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From what I have seen:

Each time you call into your insurance and get a different person the answer will change.

Medicare is having to follow rules put into affect by ACA which include star ratings and MTM (medication therapy management). Many changes had a tiered timing from when ACA went into law, 1, 3, 5..., years out.

A few years ago when combo drugs that had acetaminophen in them (vicodin/lortab, percocet) were capped at 325mg it was 'cause of ACA' while it sounded like a BS answer it was true:

https://www.gpo.gov/fdsys/pkg/FR-201...f/2011-709.pdf


I haven't read every page of ACA and I don't plan on it, but I wouldn't be surprised that while is might not specifically state in ACA that TSH levels need to be checked every 6 months, it might have a clause that states something along the lines of the insurer getting a better rating if chronic disease(s) are followed through regularly and preventative maintenance is the best cost effective way to do that.

Which in turn will result in the insurer/MD office/ACA saying, 'studies show that if the patient meets with the MD every 6 months for their thyroid, cholesterol, blood pressure, etc. It increases patient compliance and x.x % less patients having a serious event and or cutting down on ER visits' success, it works.
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Old 01-16-2016, 04:45 PM   #18
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They will cover the once per year blood test but you need to make sure your doctor codes the request properly. I just ran into this with BCBS during my annual physical last month. For some reason the doctor coded the blood work as diagnostic and BCBS wouldn't reimburse the cost as part of my annual preventive care. I had to get my doctor to resubmit the blood work request as preventive care.

You and I must have the same doc. Mine did the same thing to me. I called my doctors office and told them that she coded the lab work incorrectly. The office said they would resubmit the codes but seemed really snooty about it. Weird. It's the doc's error, not mine.

Using incorrect codes to get higher reimbursement is fraud. I've seen it over and over again in many settings. But it is really hard to report this stuff. And very hard to catch.


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Old 01-16-2016, 05:16 PM   #19
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Narcotics prescribing regulations are driven by your state, not the ACA. My state made several changes while I was still w*rking -- all of them prior to the ACA. The DEA may be working with states to implement tighter narcotics regulation. It's a chronic problem, but unrelated to the ACA.

Your doctor's medical group may be attempting to implement standards that require closer follow up of chronic disease, but six month follow up for routine medications like levothyroxine or oral contraceptives seems like an overly enthusiastic reaction to some of the incentives in the ACA. Certainly it's not a direct requirement of the ACA, just over-response to some of the goals. Since it's in your doc's best intere$t to $ee you more frequently, it may also simply be his or her $pecial interpretation.
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Old 01-16-2016, 07:38 PM   #20
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Kids say the dog ate my homework. Medical providers say Obamacare made me do it.
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I'm always amused at the never-ending ways the ACA gets the blame for all sorts of things it has no part in creating.
+1 but I find it annoying rather than amusing.
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