Specialist in-network, but lab isn't-How does anyone figure out all the ins and outs?

[Potstickers]

Quote:

Originally Posted by AbbA I'm sorry, but could you please elaborate how this works? Who do you ask for the lab order: the lab technician who draws your blood or the doctor whom I usually see a week after the lab work? Actually, what is a lab order? If you wish for Quest, shouldn't those tubes of blood go directly to Quest? Does Quest also do test on urine if it's a special kind of test? I think you really need to know all the delicate in and out information to carry the whole discussion because some of those people are not really approachable or lack CS skills. E.g. the woman who draws my blood is *always* grouchy with me. I would be afraid to ask her to do something unusual. If I'm brave enough I'll ask her what lab my blood goes to. Would it correct to assume that the hospital labs could be covered by the same in-network contract as the doc or can the insurance (BSBC in our case) say "we cover the doc or the doc and the hospital BUT not the lab"? Anyway you really sound VERY knowledgeable... Now, speaking of my visit re potential colonoscopy, today I was told that my red cells have improved since the lab work 3 months ago. We scheduled my next blood draw in 3 months and then the following will be in 6 months. This is in order to establish that it stays stable. I've been religiously taking my iron pills on an empty stomach 1 hour prior to food intake. My DH also started feeding me some red meat and liver. I don't think my organism absorbed iron from spinach and kale that much. I hope the results will be favorable again and I can avoid colonoscopy. BTW, the doc mentioned that the regulation is changing and supposedly colonoscopy is highly recommended at age of 45. She hopes that insurance companies will start to cover it at 45.

I just tell the doctor that I want to get the bloodwork run at Quest and ask for the order. Then, I set up an appointment at a convenient Quest location inside the Safeway near me (or walk in if I want to do it the same day), hand over the order, and get the blood drawn. Haven't done urine tests with them, but I could. If the doctor orders a blood test sometime other than when I'm in for an appointment, I ask the doctor's nurse to forward to order to the Quest location. (I have the Quest phone and fax number ready.) Easy. Avoids a lot of out-of-network surprise issues and lets me track results & history.

[audreyh1]

I always make sure that the phlebotomist is sending the samples to the lab my insurance prefers. I have an account at Quest (oops, breach!) so I always get my results in a timely manner.

But in the OPs case this wouldn’t have worked because it was a new, unique test performed by a particular company. So it wouldn’t have mattered. Either have the new test done which apparently offered a better screening, or go with the older methods which are considerably more invasive and risky? I might have been happy paying for the less invasive approach.

The real problem is the doctor didn’t explain the situation.

[RetMD21]

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Originally Posted by AbbA We'll see how long it will take our bill. I don't think we should go looking for it, should we? Unless the BSBC rep really added the fax # and sent the claim back to the claims department, it might be sitting as 'closed/finalized', but nothing sent to the provider (Exosome in this case). Generally speaking: Are patients supposed to look for bills or should they let them come to them? I am always concerned not to receive some kind of letter from collections because somebody drags feet to communicate to us or the mail gets lost.

I think BCBS will eventually change their policy. Reducing unproductive biopsies is good for BCBS and the patient. You might be able to argue with them on this. I wouldn't ask for a bill and they might not send one or they might not send a second. I understand you concern about collections.

I would have guessed that the list price would be higher. Maybe they are waiting for insurers to allow the test.

[sengsational]

The only thing we have to leverage is not paying the bill. I extend this to not paying any bill associated with the encounter, no matter what entity is trying to extract money from me. This way, more entities are kept "interested" in helping me find a solution. There can be problems with this approach, obviously, but more on that later.

Step one: You need to add something to those forms they make you fill-out when visiting a doctor. They ask you for essential health information right along side a bunch of stuff to make sure they can collect money from you, like your social security number (which you NEVER give them). So somewhere in the region where they're slyly asking you information about how best to collect money from you, you write "Any procedure, service, or billable item, from this office or another entity must be approved by me in advance." (or something like that). Then take a picture of that form with your phone. They will probably say "we can't do that". Fine, they can scratch it off the form (you have your photo).

Scenario "disclosed out of network": So you get in there and they say we use "LabOTheFuture". You say "how much?" They say "I dunno". You say "Find out." They say "It depends". To this, you call BS. There is nothing unknown or secret here. There's no insurance involved. They know the price, they're just stonewalling. Get the price out of them. If you agree to it, you owe it. Done.

Scenario "in-network": You get in there and they say we use a lab that's in network and you need a test. You say "how much?" They say "I dunno". And they don't! There's a secret contract between the lab and the insurance company! In this case, you must trust your insurance company to have done a good job negotiating the rate and just be thankful it's in-network.

Scenario "undisclosed out of network": You get blind-sided after a visit. Maybe you had no idea there was even a second, third, fourth or fifth party (you thought you just went to the doctor, first party). Don't pay anybody. Relax. Wait two months. Don't call anybody. Ignore anybody who calls you. Wait for everything to get exchanged with the insurance company. This is easier to do for encounters that are not "ongoing", but the idea might be able to be extended to those types of situations too. If the bills from all parties are not to your liking, call your doctor's office and tell the finance person that nobody's getting a dime until you're happy with all of the bills. Give the financial person there at your doctor's office a copy of the form where you added the stipulation concerning being notified of out of network services.

Here is the point where you document everything and make sure all entities know that you're planning to open a case with your state's attorney general. Give that a week and see if that saber rattling works. If not, go ahead and open a case. Maybe it'll work, maybe not.

If your attorney general's office doesn't help, let each entity send you to collections if you're not satisfied. Or, if you "need" to do future business with one of the entities, you can negotiate that bill or just pay it. The point is, don't be afraid of collection agencies, they can be ignored easily.

So now you get the letter from the collection agency. You write a certified letter, known as a "drop dead" letter disputing the debt and that you have source documentation that indicates the debt is invalid (that picture you took of the form where you added the stipulation). And you threaten to sue them in your local small claims court if they impact your credit rating (a right afforded you by the Fair Debit Collection Practices Act).

I doubt it will come to it, but if they sue you, make sure you show up in court with your document. You might just win. If you get a judgement against you and you're concerned that being on the public record as someone who's got a judgement against you, pay the bill. If you don't care that you've got a judgement against you, STILL don't pay it. They don't throw you into debtors prison nowadays. If they put a mark on your credit report, you could sue them in your small claims court (mine costs $99), but I'd probably just ignore it. Unless you're going to be trying to get a loan in the future, small claims process is just a long and stressful thing you don't need to go through.

The more people that get "hard nosed" with "the system", the more they'll start respecting us as consumers. The patient is the patsy. Toughen-up. They've got the deck stacked against the consumer. Use whatever rules we have on our side to combat the messed-up system.

[AbbA]

Sengsational: This is a well explained instruction on how to act, but I think I would be a chicken to get this tough to let it go all the way to suing a collection agency. I don't even want to get to the collections agency. We still work FT and have school aged kids who might go to college and we'll need loans for that probably. I wouldn't want to jeopardize our busy life even more at this time. I will wait for the bills patiently.
Since the results of the additional tests for both us turned out in our favor it doesn't feel that awful to pay the bills because they should come to the end, but like Audrey said keeping us in the blind spot it feels kind of dishonest.

[AbbA]

Quote:

Originally Posted by Potstickers I just tell the doctor that I want to get the bloodwork run at Quest and ask for the order. Then, I set up an appointment at a convenient Quest location inside the Safeway near me (or walk in if I want to do it the same day), hand over the order, and get the blood drawn. Haven't done urine tests with them, but I could. If the doctor orders a blood test sometime other than when I'm in for an appointment, I ask the doctor's nurse to forward to order to the Quest location. (I have the Quest phone and fax number ready.) Easy. Avoids a lot of out-of-network surprise issues and lets me track results & history.

Awesome. I'm glad I asked and I appreciate you explaining it. I didn't have a clue about this and I'll research this for our city.
However, I have a question: Is this just your preference to have the lab work done with Quest or are you sure that prices of Quest will always beat prices of a hospital's lab if it's covered by BSBC? If because you do this primarily due to better pricing by Quest how do you find out and compare the prices and the allowed amounts to reach a decision that Quest wins?
If you're FIRE'd then yes, you don't mind making dozens of calls. It's quite different when you work and work hours mostly coincide with the work hours of people you try to reach .

[AbbA]

Quote:

Originally Posted by Helena Usually... if your in-network PCP or in-network specialist uses an out-of-network lab without your knowledge, the patient is held harmless and network benefits are paid for the out-of-network lab. But that might not happen when the claim is first processed. If it doesn't, you should contact BCBS, explain the situation and ask them to adjust the lab claim to pay in-network. Also, if there is an allowable amount difference, the lab charge should allow in full.

Well, Helena, I did try to point this out to the rep of BCBS, but her answer was "BCBS doesn't have a contract with this provider. Your deductible is very high ($6k I think) and you're haven't reached it. You're on the hook for the full price."

I tried to explain to this rep that we were blind-sided. We didn't know about the test being sent outside the urologist's office until the last minute. I do admit that I didn't even have a clue that my DH was supposed to immediately react and inquire 'where are you sending? is it in network?' and then make a decision on the spot whether to agree to this or not.

How can BCBS adjust this out-of-network and no-contract-with lab test?
If it's feasible, who would pay the difference to the provider considering that we have not met the deductible yet?
In other words, there is something else at play in these insurance and provider dealings. When we signed up for this high-deductible & HSA plan a few years ago, I got very concerned about in-network and out-of-network prices and deductibles since we travel as a family. So, we asked BCBS once "If we are unfortunate and get in a serious car wreck while traveling, how can we possibly find out of in-network hospital when we need immediate help?" The short answer was "you'd be billed in-network pricing".

Does anyone know how to solve this puzzle?
If emergency services are provided by out-of-network providers I'm guessing BCBS doesn't have contracts with such providers. Right or not? If right, then how does it determine the right 'in-network' allowed amount for me to pay?
This reminds me that I should call BSBC and ask if it's still true (in-network pricing for out-of-network providers in an emergency situation while traveling far away from home).

[Potstickers]

Quote:

Originally Posted by AbbA Awesome. I'm glad I asked and I appreciate you explaining it. I didn't have a clue about this and I'll research this for our city. However, I have a question: Is this just your preference to have the lab work done with Quest or are you sure that prices of Quest will always beat prices of a hospital's lab if it's covered by BSBC? If because you do this primarily due to better pricing by Quest how do you find out and compare the prices and the allowed amounts to reach a decision that Quest wins? If you're FIRE'd then yes, you don't mind making dozens of calls. It's quite different when you work and work hours mostly coincide with the work hours of people you try to reach .

Quest (and LabCorp) are two of my insurer's preferred providers for lab services -- in network, and from what I can tell, good pricing. The hospital lab is also in-netwrok, but they are not preferred and the prices are higher. We have a HDHP, so I'm moderately careful on expenditures. There are small differences between Quest and LabCorps pricing, but not enough to make me want to use two labs. Quest's patient portal with historical records is a big enough plus for me that I stick with them unless I need a test they can't run. Not worth a lot of phone calls.

However -- imaging is a whole different area. I got x-rays and an MRI at an in-network standalone provider that was tremendously cheaper than my in-network hospital outpatient radiology department. Saved close to $1K. That was worth a few phone calls.

[Amethyst]

I'm glad you are OK.

That said, my husband had this happen (Federal BCBS). He saw our in-network physician, who prescribed a particular test, which at the time was fairly new. We had never before been billed directly for a test, so didn't think to ask questions.

Eventually, we got a bill for the full lab charge, about $700.00. BCBS said, "Too bad, they used an out-of-network lab to read the results."

Nothing we could do about it, except vow to ask every physician, in future, about the provenance of every single test and lab that interprets the test. Just as you said - right there in the office, before they submit the Dr's order to the lab! Never mind if you are sick, possibly in pain, and worried stiff. Gotta do your due diligence!
.

[zinger1457]

Quote:

Originally Posted by AbbA How can BCBS adjust this out-of-network and no-contract-with lab test? If it's feasible, who would pay the difference to the provider considering that we have not met the deductible yet? In other words, there is something else at play in these insurance and provider dealings.

Unless there's a healthcare regulation requiring a change what's the incentive for BCBS or any other insurer to make adjustments or change the way the out of network billing works? As you've found out it benefits the insurer for you to use out of network doctors/labs, even if you're not aware of it until after the fact.

[AbbA]

Quote:

Originally Posted by Amethyst I'm glad you are OK. That said, my husband had this happen (Federal BCBS). He saw our in-network physician, who prescribed a particular test, which at the time was fairly new. We had never before been billed directly for a test, so didn't think to ask questions. Eventually, we got a bill for the full lab charge, about $700.00. BCBS said, "Too bad, they used an out-of-network lab to read the results." Nothing we could do about it, except vow to ask every physician, in future, about the provenance of every single test and lab that interprets the test. Just as you said - right there in the office, before they submit the Dr's order to the lab! Never mind if you are sick, possibly in pain, and worried stiff. Gotta do your due diligence!

Thank you for posting. That's exactly how it usually plays out. Consumer/patient is always at the losing end.

Anyway, now I wish this forum had a 'sticky' thread of what things to research before going to a doc, questions one should ask at a primary doc's or a specialist's office or even to how handle a process for lab work or imagining to avoid surprises later. Do we have something like that here? Would there any interest to have it?

[AbbA]

Quote:

Originally Posted by Potstickers Quest (and LabCorp) are two of my insurer's preferred providers for lab services -- in network, and from what I can tell, good pricing. The hospital lab is also in-netwrok, but they are not preferred and the prices are higher. We have a HDHP, so I'm moderately careful on expenditures. There are small differences between Quest and LabCorps pricing, but not enough to make me want to use two labs. Quest's patient portal with historical records is a big enough plus for me that I stick with them unless I need a test they can't run. Not worth a lot of phone calls. However -- imaging is a whole different area. I got x-rays and an MRI at an in-network standalone provider that was tremendously cheaper than my in-network hospital outpatient radiology department. Saved close to $1K. That was worth a few phone calls.

Thank you for your instructive feedback about Quest and LabCorps.

Thanks everyone for sharing your experiences. It was very informative to me. Until this year the only times we saw our primary doctors were on the wellness visits. We were totally rookies. I must prepare for the future visits.

[ziggy29]

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Originally Posted by sengsational The only thing we have to leverage is not paying the bill. I extend this to not paying any bill associated with the encounter, no matter what entity is trying to extract money from me. This way, more entities are kept "interested" in helping me find a solution. There can be problems with this approach, obviously, but more on that later.

This is why I recommend that people *not* set up their insurance to automatically pay claims from their HRA or HSA. If you dispute a claim, you may have a lot more leverage and success if you won't pay until the matter is resolved. If you paid already, there is very little incentive or urgency for the provider to work through your disputes. Nope, send me the EOB and the bill, and if I agree with the EOB and the charges, I pay it. Otherwise, you'll be getting a phone call from me explaining what I don't believe I should pay, and why.

[Drewskers]

Washington state recently passed a law (effective effect Jan. 1, 2020) prohibiting many of the situations being discussed in this thread:



https://www.insurance.wa.gov/surprise-medical-billing

[RetMD21]

Quote:

Originally Posted by AbbA Well, Helena, I did try to point this out to the rep of BCBS, but her answer was "BCBS doesn't have a contract with this provider. Your deductible is very high ($6k I think) and you're haven't reached it. You're on the hook for the full price." I tried to explain to this rep that we were blind-sided. We didn't know about the test being sent outside the urologist's office until the last minute. I do admit that I didn't even have a clue that my DH was supposed to immediately react and inquire 'where are you sending? is it in network?' and then make a decision on the spot whether to agree to this or not.

Is BC just applying this to your deductible? That's different than a disallowed charge. I think the rep is probably right that you have to pay unless you want to risk collections and court.

[ziggy29]

Quote:

Originally Posted by Drewskers Washington state recently passed a law (effective effect Jan. 1, 2020) prohibiting many of the situations being discussed in this thread: https://www.insurance.wa.gov/surprise-medical-billing

We're keeping an eye on our northern neighbor. (We're only 20 miles from the state line.) They have no income tax, too. Of course, we have no sales tax in Oregon, and they will get you one way or another, but eventually moving just over the Columbia is not out of the question for us at some point, maybe after full retirement for both of us.

The Costco and Home Depot nearest us, a 10 minute drive from the state line, often has about 1/3 Washington plates.

[saydiver]

I know some BCBS plans have an Exclusive Provider Provision in their contract for ancillary services such as pathology services. The Summary of Benefits may not mention this exclusion and you actually have to look at the plan's contract to find this info. In Florida FL Blue's Blue Select plans have this limitation. Check your contract to see if your plan has a similar limitation.

[Smitty700]

Quote:

Originally Posted by Drewskers Washington state recently passed a law (effective effect Jan. 1, 2020) prohibiting many of the situations being discussed in this thread: https://www.insurance.wa.gov/surprise-medical-billing

Texas did the same thing in the legislative session that just ended. It has yet to be signed by the governor, but it is expected it will as it passed overwhelmingly.

Texas already had a system set up to arbitrate bills more than $500. This new law is much more comprehensive.

[sengsational]

According to Consumer Reports, as of a year or two ago, 23 states had laws against slipping in out of network services, with New York having a strong law that does what most of us probably want...just pay the in-network rate. CR used to have a page with each state and where exactly to go to get help working out these problems, but I can't find it at the moment. I did find this page and it mentioned patientadvocate.org, which I don't know about, but might be a thing to try.

[DougJohnson]

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Originally Posted by AbbA As soon as I hang up, I call BCBS and get a 'gatekeeper' so to speak... [lots of friendly lack of help]

I dropped BCBS for just this reason. Their customer no-service couldn't do anything. I had a claim that they wouldn't pay. Kept saying they hadn't received it even though I had sent it four times, including two with return receipts. Customer no-service only suggestion was to send it again. Sometimes they suggested a different PO Box. Useless.

-- Doug