Lack of Transparency Still. Blood Tests. Rant.

[John Galt III]

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.

[ERhoosier]

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/

[rbmrtn]

Quote:

Originally Posted by John Galt III 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!/

[Turboslacker]

The whole medical system frustrates the heck out of me especially the billing aspect.

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[MBSC]

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).

[NoMoreJob]

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).

[Animorph]

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.

[MRG]

Quote:

Originally Posted by Animorph 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

[ShortInSeattle]

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.

[M Paquette]

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...

[Live And Learn]

Quote:

Originally Posted by M Paquette 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 !

[Alan]

Quote:

Originally Posted by M Paquette 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.

[ERhoosier]

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

[John Galt III]

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 !!!

[Katsmeow]

Quote:

Originally Posted by Alan 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)

[Alan]

Quote:

Originally Posted by Katsmeow 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.

[John Galt III]

Quote:

Originally Posted by John Galt III 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.

[Alan]

Quote:

Originally Posted by Katsmeow 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 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)

[sengsational]

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.

[Alan]

Quote:

Originally Posted by sengsational 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.