Join Early Retirement Today
Reply
 
Thread Tools Search this Thread Display Modes
Lack of Transparency Still. Blood Tests. Rant.
Old 01-26-2014, 11:41 AM   #1
Thinks s/he gets paid by the post
John Galt III's Avatar
 
Join Date: Oct 2008
Posts: 1,285
Lack of Transparency Still. Blood Tests. Rant.

I have Obamacare now, for a nice low monthly premium. But the same problem exists that I used to sometimes have before. I'm trying to find out if certain blood tests that my doctor ordered, are covered by the new insurer. I'm getting bounced all over the place.

The insurer says they need to know the "procedure code" also known as the CPT code, for each test. I have a paper requisition for the blood tests from the doctor, but the CPT codes are blank for 2 of them. The full names of the tests are on the requisition, but the ins co only wants the CPT codes.

I won't go into the other multiple levels of responsibility-shifting I've been getting about who determines the CPT codes, but it has finally come down to getting a person in my doctor's office to tell me what the darn CPT codes are.


A nice customer service lady at my new ins co offered to take the ball and run with it (which amazed me ) and she is now calling my doctor's office to get them to give her, with my permission, the CPT codes. At first, dr's office said there was a "software glitch" that was preventing them from having a CPT code, but they would get the glitch fixed, and call her back. Several days later, the nice cs lady is leaving messages at dr's office, but not getting her calls returned.

Earlier, I had called my dr's office about the CPT codes, and they suggested getting them myself from Google and just writing them on the requisition form myself !!!


Very frustrating. Rant over. Thanks for listening.
__________________

__________________
John Galt III is offline   Reply With Quote
Join the #1 Early Retirement and Financial Independence Forum Today - It's Totally Free!

Are you planning to be financially independent as early as possible so you can live life on your own terms? Discuss successful investing strategies, asset allocation models, tax strategies and other related topics in our online forum community. Our members range from young folks just starting their journey to financial independence, military retirees and even multimillionaires. No matter where you fit in you'll find that Early-Retirement.org is a great community to join. Best of all it's totally FREE!

You are currently viewing our boards as a guest so you have limited access to our community. Please take the time to register and you will gain a lot of great new features including; the ability to participate in discussions, network with our members, see fewer ads, upload photographs, create a retirement blog, send private messages and so much, much more!

Old 01-26-2014, 12:05 PM   #2
Thinks s/he gets paid by the post
 
Join Date: Feb 2011
Posts: 1,629
Might also try calling local labs. The lab also bills for their testing service using those CPT codes, so they need to know those too.

Also keep in mind that certain CPT codes might be covered or NOT covered by your ACA policy depending upon whether or not the doc lists them as "preventative" test AND the lab & doc are "in network". In network "Preventative" stuff, as defined by gov't, is fully covered. But even that gets confusing. For example, same cholesterol blood test done in network might be covered (no copay) as a screening test but not (i.e. subject to copays/deductibles) if ordered to follow someone with known high cholesterol.

https://www.healthcare.gov/what-are-...care-benefits/
__________________

__________________
ERhoosier is offline   Reply With Quote
Old 01-26-2014, 12:29 PM   #3
Thinks s/he gets paid by the post
 
Join Date: Jul 2012
Location: Mississippi
Posts: 1,878
Quote:
Originally Posted by John Galt III View Post


Very frustrating. Rant over. Thanks for listening.
Just like everything else in our medical system. For your insurance to pay it, the doctors office has to "code" it correctly. If the doctors billing office doesn't know what the code is , that doesn't make sense. How can they order something that doesn't have a code, Another problem is the AMA is in control of the code and don't make them easily accessible.

This an article that explains some of the problem, CPT Codes Are Current Procedural Terminology Codes

The online labs may be able to help. Here's a link to LabCorp, you can look up test and there is CPT code for the test

https://www.labcorp.com/wps/portal/!...CMDVDRTEwRzY!/
__________________
rbmrtn is offline   Reply With Quote
Old 01-26-2014, 01:54 PM   #4
Recycles dryer sheets
 
Join Date: Jan 2014
Posts: 243
The whole medical system frustrates the heck out of me especially the billing aspect.

Sent from my HTC One using Early Retirement Forum mobile app
__________________
Turboslacker is offline   Reply With Quote
Old 01-26-2014, 02:32 PM   #5
Full time employment: Posting here.
 
Join Date: Jan 2014
Posts: 662
As stated earlier, the CPT code will need to be billed by an "in network" provider. If it's not a preventive test, the covered test will most likely be applied to your deductible if the deductible has not already been met or have a co-payment due. In addition to billing CPT codes that are covered, the ICD-9 diagnosis code will also need to be covered. An insurance claim submitted with a covered CPT code but a non-covered diagnosis will result in a rejected claim (non-payment).
__________________
MBSC is offline   Reply With Quote
Old 01-26-2014, 03:49 PM   #6
Recycles dryer sheets
NoMoreJob's Avatar
 
Join Date: Feb 2012
Posts: 169
Once you get it all figured out, keep your fingers crossed that it all actually gets coded properly once the tests are completed and billed! The coding fiasco is serving to increase, not decrease the complexity of our healthcare system. Unfortunately it's often like a 'who's on first' comedy skit. I know this from multiple first-hand experiences and I require very little medical care (but pay for most of my own due to having a HDHP so I have significant skin in the game as a consumer).
__________________
NoMoreJob is offline   Reply With Quote
Old 01-26-2014, 07:15 PM   #7
Thinks s/he gets paid by the post
 
Join Date: Jul 2005
Posts: 3,862
Your doctor should have been able to give you the CPT's. That was his responsibility. Suggesting Google was really flakey. I'd go to a better doc to start.
__________________
Animorph is offline   Reply With Quote
Old 01-26-2014, 10:04 PM   #8
Give me a museum and I'll fill it. (Picasso)
Give me a forum ...
 
Join Date: Apr 2013
Posts: 5,581
Quote:
Originally Posted by Animorph View Post
Your doctor should have been able to give you the CPT's. That was his responsibility. Suggesting Google was really flakey. I'd go to a better doc to start.
The codes have grown exponentially over the last few years. Nothing to do with ACA, pressure to do more with less, providing better care.

I agree, your DR's office suggesting to go Google these yourself is about like telling you to go do something else to yourself.

The provider (DR's pratice) is responsible for providing the codes IMHO. They are providing the service. If they don't know what tests or why their ordering a test, perhaps there is a different problem.

Glad your payer is helping out.
MRG
__________________
MRG is online now   Reply With Quote
Old 01-27-2014, 12:02 AM   #9
Full time employment: Posting here.
ShortInSeattle's Avatar
 
Join Date: Jan 2012
Location: Seattle
Posts: 517
When I worked in healthcare, I learned that most codes are assigned AFTER the procedure is complete. Also, many doctors know very little about codes.

1. Patient books appt.
2. Appointment occurs.
3. Doc makes notes on what they did.
4. Coders review notes and assign codes. Codes can be complex. Two visits for the same condition can have different codes depending on what was discussed and done.
5. Billing sends bills to insurance.

This system makes providing estimates very difficult. Coders need to code based on what was documented, and docs are trained to provide the right kinds of documentation to maximize billing. (Not to lie, but to avoid "undercoding") The hospitals don't want to leave money on the table. Docs never know what to expect until they see the patient, so that is a factor too.
__________________
ShortInSeattle is offline   Reply With Quote
Old 01-27-2014, 12:32 AM   #10
Moderator Emeritus
 
Join Date: Oct 2007
Posts: 4,929
Medical coding is it's own specialized field, with schools, continuing education programs, and certifying organizations like the American Academy of Professional Coders (AAPC).

There are actually 'mere' generalist coders, and a bunch of 'specialist' coder areas for everything from pediatrics or family practice to foot and ankle surgery specialists. It has become that complex... And then there are the medical coding auditors and compliance specialists...
__________________
M Paquette is offline   Reply With Quote
Old 01-27-2014, 03:37 PM   #11
Thinks s/he gets paid by the post
Live And Learn's Avatar
 
Join Date: Feb 2012
Location: Tampa Bay Area
Posts: 1,689
Quote:
Originally Posted by M Paquette View Post
Medical coding is it's own specialized field, with schools, continuing education programs, and certifying organizations like the American Academy of Professional Coders (AAPC).

There are actually 'mere' generalist coders, and a bunch of 'specialist' coder areas for everything from pediatrics or family practice to foot and ankle surgery specialists. It has become that complex... And then there are the medical coding auditors and compliance specialists...
I actually considered this as a SER career ... but then it sounded like way to much w*rk !
__________________
"For the time being no discipline brings joy, but seems grievous and painful; but afterwards it yields a peaceable fruit of righteousness to those who have been trained by it." ~
Hebrews 12:11

ER'd in June 2015 at age 52. Initial WR 3%. 50/40/10 (Equity/Bond/Short Term) AA.
Live And Learn is offline   Reply With Quote
Old 01-27-2014, 04:13 PM   #12
Moderator
Alan's Avatar
 
Join Date: Jul 2005
Location: Eee Bah Gum
Posts: 21,108
Quote:
Originally Posted by M Paquette View Post
Medical coding is it's own specialized field, with schools, continuing education programs, and certifying organizations like the American Academy of Professional Coders (AAPC).

There are actually 'mere' generalist coders, and a bunch of 'specialist' coder areas for everything from pediatrics or family practice to foot and ankle surgery specialists. It has become that complex... And then there are the medical coding auditors and compliance specialists...
I once listened to a professional coder being interviewed on the radio and realized what a complex game this is. The person being interviewed traveled the country giving seminars to medical professionals on how code procedures to get around the restrictions HI companies pay for "reasonable and customary" procedures. She sounded a bit like a tax pro who offers to get a bigger refund if you pay to have her prepare your return.

In December DW and I had colonoscopies on the same day, one after another, and I now have the EOB's on all the charges. The surgical centre, the doctor, and the lab that did the test on the polyps all charged exactly the same mount even though DW had 1 more polyp than me removed and sent for testing. However, the anesthetist charged more for me than DW. Who knows why, I'm heavier and more drugs used maybe, but the other charges were identical even though she had 50% more polyps to be removed and tested.

We also each have a charge of $750 each from the "Gastroenterology & Liver Association" that is out of network and fully payable by us. Not had the invoices from them yet so I don't know what they did or even who they are (Google hasn't helped and of course the EOB has no detail). I'll be querying the invoices once I get them, and it really ticks me off that before going into the procedure I did check that the doctor and surgery center was in network. We both did the procedure in December as we had both fulfilled our deductible for the year, so this out of network, out of the blue, charge dwarfs all the other charges that I've paid for the procedure.
__________________
Retired in Jan, 2010 at 55, moved to England in May 2016
Now it's adventure before dementia
Alan is offline   Reply With Quote
Old 01-27-2014, 04:19 PM   #13
Thinks s/he gets paid by the post
 
Join Date: Feb 2011
Posts: 1,629
More insight into CPT codes, inc AMA's ownership, copyright, and income from them-

The AMA and CPT Codes - Getting Picky and On My Case

BTW- AMA does NOT represent most US docs anymore since less than 20% are members.
AMA: Delegates Question AMA Role in Health Reform
__________________
ERhoosier is offline   Reply With Quote
Old 01-29-2014, 10:50 AM   #14
Thinks s/he gets paid by the post
John Galt III's Avatar
 
Join Date: Oct 2008
Posts: 1,285
Thanks for all the replies. Still not 100 percent transparency going on, but I went ahead and had the blood tests done. I found out from the internet what the CPT codes would be (supposedly) for the tests, and just verified with my ins co that those CPT codes would be covered, with the diagnosis codes I had on the lab form. Keeping fingers crossed. No bill yet.

At least my monthly premium is low !!!
__________________
John Galt III is offline   Reply With Quote
Old 01-29-2014, 10:59 AM   #15
Thinks s/he gets paid by the post
Katsmeow's Avatar
 
Join Date: Jul 2009
Posts: 3,399
Quote:
Originally Posted by Alan View Post

We also each have a charge of $750 each from the "Gastroenterology & Liver Association" that is out of network and fully payable by us. Not had the invoices from them yet so I don't know what they did or even who they are (Google hasn't helped and of course the EOB has no detail). I'll be querying the invoices once I get them, and it really ticks me off that before going into the procedure I did check that the doctor and surgery center was in network. We both did the procedure in December as we had both fulfilled our deductible for the year, so this out of network, out of the blue, charge dwarfs all the other charges that I've paid for the procedure.
Be sure and check your policy. Some policies provide that the policy will pay the in network rate for certain out of network providers if the facility itself is in network. That doesn't protect you from balance billing but can cause the insurer to have to pay at the in network rate than out of network rate which does help some. I know that on the last couple of policies I've had they have listed when they will do this. I had one procedure a few years OK where they initially paid out of network rates, we questioned it (due to the policy provision) and they then paid the provider the in network rate (and the provider accepted this as full payment, thankfully)
__________________
Katsmeow is offline   Reply With Quote
Old 01-29-2014, 01:27 PM   #16
Moderator
Alan's Avatar
 
Join Date: Jul 2005
Location: Eee Bah Gum
Posts: 21,108
Quote:
Originally Posted by Katsmeow View Post
Be sure and check your policy. Some policies provide that the policy will pay the in network rate for certain out of network providers if the facility itself is in network. That doesn't protect you from balance billing but can cause the insurer to have to pay at the in network rate than out of network rate which does help some. I know that on the last couple of policies I've had they have listed when they will do this. I had one procedure a few years OK where they initially paid out of network rates, we questioned it (due to the policy provision) and they then paid the provider the in network rate (and the provider accepted this as full payment, thankfully)
Thanks, I do have a query in with my insurance company.
__________________
Retired in Jan, 2010 at 55, moved to England in May 2016
Now it's adventure before dementia
Alan is offline   Reply With Quote
Old 02-15-2014, 09:23 AM   #17
Thinks s/he gets paid by the post
John Galt III's Avatar
 
Join Date: Oct 2008
Posts: 1,285
Quote:
Originally Posted by John Galt III View Post
Thanks for all the replies. Still not 100 percent transparency going on, but I went ahead and had the blood tests done. I found out from the internet what the CPT codes would be (supposedly) for the tests, and just verified with my ins co that those CPT codes would be covered, with the diagnosis codes I had on the lab form. Keeping fingers crossed. No bill yet.

At least my monthly premium is low !!!

Update: I received the EOB for the blood tests, and I owe $5 copay, plus $5.75 for the blood draw. Total $10.75. Not bad. All the blood tests were taken care of by ins co, I owe nothing for them. The CPT codes they used were indeed the ones I found on the internet.
__________________
John Galt III is offline   Reply With Quote
Old 02-15-2014, 10:56 AM   #18
Moderator
Alan's Avatar
 
Join Date: Jul 2005
Location: Eee Bah Gum
Posts: 21,108
Quote:
Originally Posted by Katsmeow View Post
Be sure and check your policy. Some policies provide that the policy will pay the in network rate for certain out of network providers if the facility itself is in network. That doesn't protect you from balance billing but can cause the insurer to have to pay at the in network rate than out of network rate which does help some. I know that on the last couple of policies I've had they have listed when they will do this. I had one procedure a few years OK where they initially paid out of network rates, we questioned it (due to the policy provision) and they then paid the provider the in network rate (and the provider accepted this as full payment, thankfully)
Quote:
Originally Posted by Alan View Post
Thanks, I do have a query in with my insurance company.
I now have a formal written appeal in with BCBS, on the basis that you mention, plus the lab that ran the tests have also made an appeal on the same grounds. (The RAP clause - Radiologist Anesthesiologist Pathologist)
__________________
Retired in Jan, 2010 at 55, moved to England in May 2016
Now it's adventure before dementia
Alan is offline   Reply With Quote
Old 02-15-2014, 12:04 PM   #19
Thinks s/he gets paid by the post
sengsational's Avatar
 
Join Date: Oct 2010
Posts: 3,837
It annoys me that doctors will select the "subcontractors" that suit them, and then let the customer duke it out with the subcontractor. So you might end-up with an out of network anesthesiologist when the community is full of in-network ones. Then, since they have your insurance info from your main doctor, they get paid something less than their outragous rate and bill you the rest. I want them to have $0 from me or my insurance company to start with, then I'd give them a take it or leave it offer of whatever the in-network rate is.
__________________
sengsational is offline   Reply With Quote
Old 02-15-2014, 12:35 PM   #20
Moderator
Alan's Avatar
 
Join Date: Jul 2005
Location: Eee Bah Gum
Posts: 21,108
Quote:
Originally Posted by sengsational View Post
It annoys me that doctors will select the "subcontractors" that suit them, and then let the customer duke it out with the subcontractor. So you might end-up with an out of network anesthesiologist when the community is full of in-network ones. Then, since they have your insurance info from your main doctor, they get paid something less than their outragous rate and bill you the rest. I want them to have $0 from me or my insurance company to start with, then I'd give them a take it or leave it offer of whatever the in-network rate is.
With all the labs in our area my skepticism is along the lines that the lab the doctor chose is one in which he has a financial interest.
__________________

__________________
Retired in Jan, 2010 at 55, moved to England in May 2016
Now it's adventure before dementia
Alan is offline   Reply With Quote
Reply


Currently Active Users Viewing This Thread: 1 (0 members and 1 guests)
 
Thread Tools Search this Thread
Search this Thread:

Advanced Search
Display Modes

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is On
HTML code is Off
Trackbacks are Off
Pingbacks are Off
Refbacks are Off


Similar Threads
Thread Thread Starter Forum Replies Last Post
Cost of 17 Blood Tests in Thailand ItDontMeanAThing Life after FIRE 12 01-19-2012 04:37 PM
Purchase Research Transparency RonBoyd FIRE and Money 0 08-31-2009 01:36 PM
Fasting vs non-fasting blood tests kaneohe Health and Early Retirement 3 08-28-2009 10:17 PM
Transparency of risk, complexity, Overseas investing free4now FIRE and Money 13 10-22-2008 03:52 PM
"Buy when there's blood in the streets, even if the blood is your own." dex FIRE and Money 14 09-30-2008 11:47 AM

 

 
All times are GMT -6. The time now is 12:02 PM.
 
Powered by vBulletin® Version 3.8.8 Beta 1
Copyright ©2000 - 2017, vBulletin Solutions, Inc.