Getting Health Insurance Contract Prices Prior to Service

[Buckeye]

DH and I went to see the doc today for a wellness check and to start a relationship with a local doctor in FL. We are 51 and 60 and haven't had any bloodwork done or seen a doc for 15 months. He gave us a list of lab tests and the name of a lab he recommend to self-pay and high deductible patients because their prices are good. The lab is not in our network so there is no contract price and the expense does not apply to our deductible. Quest is in our network.

The list price for all the tests (total of 9 tests and 2 blood draw charges):
Doc's recommended lab list price: $360
Quest list price: $846

Note - The test for Vitamin D levels was the most expensive at $70 for non-network lab and $215 for Quest.

So now the question is whether Quest's contract price is less than the other lab's non-contract price? Call the insurance company to get the answer prior to getting blood drawn? Wrong!!!

I called the insurance company who told me to talk to the network folks who told me to talk to the provider (Quest) who told me to talk to my insurance company. On my second call to the insurance company, I found someone who said said "we can't give out that information over the phone." I was informed Quest would have to submit a pre-determination and then my insurance company would respond to Quest with the contract prices of the tests. Only one big problem.......Quest doesn't do pre-determinations. Quest says I'll know the contract price of the tests when they submit the invoice and it is processed by my insurance company. Great. One of the reasons we have health insurance and pay those lovely monthly premiums is so we can get contract pricing and don't have to pay list price. What is the big secret? I'm the one who ultimately pays the bill!

What a goat rope! Will the Quest contract rates be less than the out-of-network or much more expensive? Apparently there is no way to know this until I have commited myself possibly an $846 bill from Quest. Technically, the contract rate for Quest tests could be the list price. Who knows at this point.

After several hours of back and forth and many phonecalls, we decide to just go ahead and use the out-of-network lab. I have contacted my agent and with his assistance I'm going to try and determine what the cost would have been had I used Quest. I looked back at some EOB's from when I had insurance at my previous employer and the contract price discount was about 80% off the list price. I'm going to be really upset if that is the kind of discount I would have gotten by using Quest and my cost would have been about half what I paid today.

I'm trying to be a good healthcare consumer by shopping for the best price but all I find are obstacles.

 

[clifp]

Thanks (I think) for sharing this story. I wish I could blame our current health care system on the government, unions, insurance companies, doctors, communist, or little green men from out of space, at this point my vote is for Satan. It actually makes TSA look sensible.

Disgusting..

 

[simple girl]

That's outrageous. How frustrating!

 

[Gotadimple]

The insurance company won't release specifics of what they will pay by procedure due to their contracts with providers. What they pay is considered confidential. That said:

Ask your insurance company for a pre-determination, or if they won't do it, ask Quest to get it. If they won't do it, call Customer Service to log a complaint. Also call the FL Dept of Insurance, and log a complaint.

If both Quest and the non-participating lab costs are under the deductible, I'd be tempted to go with the non-par lab just to control costs.

Finally, I'd find a new insurance company with a broader network of lab providers.

-- Rita

 

[Buckeye]

The insurance company won't release specifics of what they will pay by procedure due to their contracts with providers. What they pay is considered confidential. That said:

Ask your insurance company for a pre-determination, or if they won't do it, ask Quest to get it. If they won't do it, call Customer Service to log a complaint. Also call the FL Dept of Insurance, and log a complaint.

If both Quest and the non-participating lab costs are under the deductible, I'd be tempted to go with the non-par lab just to control costs.

Finally, I'd find a new insurance company with a broader network of lab providers.

-- Rita

The contract rates paid for tests at a particular lab may be confidential but they are going to be clearly spelled out on my EOB and I theoretically could show my EOB to whomever I wanted to show it to including a friend from LabCorp in the Contract Pricing department (don't really have one). Had the tests been done by Quest, the EOB ultimately provided to me by the insurance company would have shown Quest's full price submission, the contract discount, and the amount that is my responsibility. Because of my high deductible, I would have paid whatever the total was after the contract discount. Quest would have most likely made me pay in full when we had the blood drawn and I would have had to ask for a refund (IF contract price is less than list price) after the claim was rebilled by my insurance company.

It makes no sense to go with the non-participating lab if the contract prices for Quest are equivalent or lower than the non-par lab. Even if the costs are equivalent, by using a network provider the costs go against our deductible. If we use a non-network provider, only a percentage of the cost is applied against the deductible and I think the deductible for out-of-network charges is double the in-network deductible. Bottom line, they want us to use an in-network provider. I'm assuming this is to help drive business to the in-network providers and provide a reason for in-network providers to give a discounted rate.

My plan does have other network labs but I didn't have the list in hand when we left the Doc's office. DH and I had been fasting so we figured we might as well go get the tests done right then. My assumption is the list rates for the same tests at other network labs would not have been much different than what I was quoted by Quest. Using a different network lab still doesn't solve the main problem which is how to get the contract rates for the lab tests apriori.

 

[Buckeye]

I found someone, Sherry, at my insurance company who agreed to get with billing to give me the contract rates for my list of tests. All I needed to do was get the CPT codes for the tests. After about 3 hours of phone calls to different parts of Quest and to my doctor's office and to my insurance company (everyone initially puts me on hold), I was able to get all the information required.

I first tried to get the CPT codes by calling Quest billing. Unfortunately, I got Queen B who stated there was no way she could get me a CPT code based on the name of a test because there could be many variations of the test and she wasn't a medical professional blah, blah, blah. Her example was a Pap test but how many variations of a CBC or a CMP are there?

So now I try to call the Quest center I had been at yesterday where the nice gal at the desk seemed to have no confusion about what test I was talking about when I asked for prices. They were busy and not picking up the phone. Left message. Tried a couple of other Quest sites. Nobody answering the phone. While waiting for a call back, I decide to call the doctor's office. They don't really understand what I am talking about but I finally find someone who had some numbers for a few of the tests. She thought they were CPT numbers but it turns out they were not.

Called Quest center back again and get Nicky, the gal who I dealt with yesterday onsite. She gladly rattles off all the CBT codes for my list of tests. Now that I have the CBT codes I call Sherry back. Oops, now I need the Quest Tax ID number and NPI number. Call Quest Billing back and get a very nice lady who gives me the Tax ID and NPI numbers. Just for grins, I ask her if she could give me CPT codes for a list of tests. "Sure, no problem." We go through the list and I double-check the codes I have already been given. Everything matched.

All the info has now been submitted to my insurance company. Let's see what happens! For future savings, I hope the contract test prices are much lower than the non-network provider but I'm going to be bummed if I wasted a bunch of money going out of network. Sherry said to call her back whenever I needed help so I have a connection to check the prices of future tests.

 

[simple girl]

I am very impressed with your tenacity in attacking this! I also appreciate you sharing your story as it may help prepare me for a similar issue in the future.

 

[Buckeye]

Sherry in Claims got back with me this morning. The discounts on the specific Quest tests ranged from 66% to 82%. They used a strawman price of $50 per test and then gave me the rebilled price which gave me the discount percentage per test.

The most expensive list price was the Vitamin D test for $215 and it only had a 66% discount. The good news/bad news about that was we wasted "only" $120 by having the tests done by the non-network provider.

Non-network provider total: $360
Quest list price total: $847
Quest contract price total: $240 (72% discount over list)

As Sherry and I were talking this morning, she told me POLICY HOLDERS are allowed to submit predeterminations. We do not have to rely on the provider to submit the predetermination. Of course, the CPT codes for the tests/procedures and the tax id and NPI code of the provider (to verify exactly who they are) have to be gathered but I can do the submittal instead of the provider. Hospitals and doctors' offices typically do these submittals but it's possible to run into situations (like my situation involving lab tests) where I will need to do the submittal if I want to know the contract cost of a particular service prior purchasing the service and submitting a claim.

If only the first person I spoke to on Wednesday had given me this information instead of insisting the provider had to supply the predetermination. Sherry said an internal discussion had started regarding the incorrect information I received and the road blocks I encountered and how those issues could be corrected. I told her that was very positive but I felt it was important I submit a letter regarding my experience to American Community. She gave me the department name and fax number where I needed to send the letter. I faxed a two-page letter this afternoon. It included high praise for Sherry for taking the bull by the horns and getting me an answer.

Sometimes it pays to be hard-headed and not give up. I didn't save any money this time around but now I understand the system and I have an inside contact. I also know there are some sweet discounts on lab tests at Quest.

Two interesting things came to light while I was talking to folks trying to get info. First, the office person I talked to in my doc's office (young lady named Danielle) has no health insurance. She said she got discounted prices at Quest and that Quest worked with people to create payment plans. The second was that Sherry (helpful claims rep at American Community) had a high deductible policy ($10,000 family deductible I thought I heard her say). I don't know if American Community paid part of her deductible. She said she had been involved with lots of predeterminations during her husband's cancer treatment. She also has 2 kids. She said she had never encountered a situation with trying to get prices for lab tests but she totally understood where I was coming from. I also called Nicky back and let her know what the contract price was for all the tests. She was the gal at the desk at the neighborhood Quest site who answered all my questions about CPT codes and prices. I told her I thought she might want to know how it all turned out. She did want to know and thanked me for getting back with her.

Additional information regarding American Community is that they are now rated C for their financial health. Not good. This has gotten them suspended from writing new policies in OH. No affect on us at this point but a red flag. They have been around for at least 20 years. I hope it's 20 more years.

 

[simple girl]

Thanks for the update. This is a good learning experience for all of us new to HDHP's. Hopefully as they become more popular these issues will become less problematic. I hope?

 

[Buckeye]

One of the suggestions I made in my letter was for a secure portal where policy holders can put in CPT codes and retrieve contract prices without having to go through a predetermination. We would be using the same database the billing department currently uses. Shouldn't be a great leap to create something accessible by the policy holders.

 

[Dreamer]

I ran into the same thing when my DH had to get a PET scan. We have 2 hospitals near us and I decided to see which would be cheaper. I called the hospitals and the insurance company trying to get the info. I was told that I needed the CPT codes, so I called the doctor's office. I told her that my DH told them that he preferred X hospital and the test was scheduled for Y hospital instead and that I had decided to check prices. She stated that X hospital only had the equipment come every so often (portable) and the doctor wanted the test done ASAP at Y hospital, so I agreed to keep the test as scheduled at Y hospital. At that point, I no longer cared which place was cheaper. However, it make me understand how difficult it is to find out information to be able to make an informed decision. No wonder health care prices are so high.

 

[John Galt III]

Have some experience with this, from cash point of view. Was uninsured for a year or so and called a lab for the cash price for a certain blood test. They were able to give me a cash price, thank God. Called the same lab company, but at a different location, got a much higher cash price for the very same blood test. Went to first lab, got blood test for lower cash price, all was well.

 

[DeborahB]

What a nightmare! I have asked some of my doctors if they give a discount for cash and they do. Interesting, I thought. I have normal insurance now but if I end up with a high-deductible plan paying cash might be cheaper than trying to fulfill the deductible.

I think your doctor's office would have given you the ICD-9 codes but who knows.

 

[ziggy29]

What a nightmare! I have asked some of my doctors if they give a discount for cash and they do. Interesting, I thought. I have normal insurance now but if I end up with a high-deductible plan paying cash might be cheaper than trying to fulfill the deductible.

It can be a bit of a gamble, but if it's late in the year and you still have thousands of dollars of deductible to use up, it might be a calculated risk worth taking depending on the level of the discount.