Lab test cost and HMO I feel misled

[preexistingcondition]

Sorry I cannot make this shorter.

Went to local lab for a range of blood test.

The first lab said they did not deal with my insurer and sent us to next door in same facility.

I gave our insurance card to the nurse/ owner who said that she did deal with our insurer....they have been in business for several years and the insurance company is also local.

The insurance company did not pay as they said the lab was out of network.

In chatting the owner , at the time, she told us we were lucky that we had insurance as she always charges much more to the uninsured.

Our insurer said that the lab did have an account with them but not for HMO.

My question is:

As a local lab should she have told us that our HMO plan would be out of network if she did the test and we would have to pay ( the card clearly says HMO basic plan. )

Our insurer says they would only have paid about $300 in network to a lab not the $651 she charged.

The insurance company will not help in any way....and I can see it is not their fault.

I think the lab carried out the test knowing we would have to pay...

Any suggestions how to handle this....

 

[bentley]

uhm,....lesson learned? It is our own responsibility to know which provider is IN network.

Having said that, I do agree that the provider SHOULD have informed you.

I learned the same lesson, in the exact same way about 20 years ago, however I did get the lab to feel somewhat responsible and split the costs.

 

[bubba]

uhm,....lesson learned? It is our own responsibility to know which provider is IN network.

Having said that, I do agree that the provider SHOULD have informed you.

I learned the same lesson, in the exact same way about 20 years ago, however I did get the lab to feel somewhat responsible and split the costs.

I'm sorry to say that bentley nailed it. You ask how I know this? I had an outpatient procedure in a surgery center not included in our network. That little lesson cost me $1300, so based on that, you're getting off light. I'm sorry, but I bet this won't ever happen to you again.

I would suggest that you go back to the lab lady and have a heart to heart about discounting your bill.

 

[Martha]

I just got on a new insurance plan, Medica. The first thing I did was check all the providers I use to make sure that they were in network.

When using an unfamiliar provider I would specifically ask if they are in network with my insurer or part of my HMO.

 

[growing_older]

The first lab said they did not deal with my insurer and sent us to next door in same facility.

I gave our insurance card to the nurse/ owner who said that she did deal with our insurer

As I understand this story, the OP did check about the insurance, only to be tripped up by a technical detail - the lab works with the insurer, but isn't "in network" on that particular plan.

I don't know what else should have been expected. Do all consumers need to understand this difference for any plan and any provider that might be of service. When I've asked about coverage and process for my medical insurance I've often gotten vague or misleading answers. Requiring consumers to know more about coverage and rules than the insurance or providers own customer service people seems like an unreasonable expectation. This seems like an arbitrary rule intended to catch unwary people and not pay claims.

 

[Martha]

There are all sorts of arbitrary rules and ways to get tripped up. And with so many insurance companies and plans, each with their own rules, it also trips up the providers.

 

[brewer12345]

Call me silly, but when I want to know if a provider is in-network, etc., I call my insurer, not the provider.

 

[bubba]

What brewer12345 said. Don't ask the service provider. Call your own insurance company yourself and ask the question. Then you'll know for sure.

 

[youbet]

Call me silly, but when I want to know if a provider is in-network, etc., I call my insurer, not the provider.

There ya go........ As brewer says, it's the insurer that you need to deal with in determining if a provider is in network or not.

To save a few bucks, DW and I have coverage from two different companies as each of our former employers retiree plans has family rates higher than the sum of two individual policies. This means knowing and understanding the preferred (in network) provider list for two insurance companies and we spent several hours nailing that down. Checked our family doc, specialists we see, local hospitals and quick care clinics, labs and on and on. It was a pita, but at least it could all be done from the insurers web site.

Asking the provider is definitely not the way to go.

 

[Rich_by_the_Bay]

Call me silly, but when I want to know if a provider is in-network, etc., I call my insurer, not the provider.

You'd think so. But I remember when I was in private practice I'd terminate my participation with a carrier but they would fail to remove me from their list despite my written, return-receipt letter requesting they do so.

Of course new patients would book to be seen and had to be turned away -- we were sure to show them it was not us but rather the carrier.

 

[preexistingcondition]

I think what annoys me most is:

Firstly that I cannot trust the provider to tell me the truth.....I was deliberatly misled....the answer was yes we do test for your insurer.

Then to tell me I was lucky to have insurance and if I would have had to pay their highest rate.

Secondly that they gouged me on price.

Thirdly.... I need to become more cynical!!!!!!!!!!

 

[John Galt III]

Preexisting, I feel your pain.

You haven't really experienced health care bliss until you try to get some certain piece of info from the provider, only to be told to ask the insurer for the info, and, of course, when you ask the insurer for the info, the insurer tells you to ask the provider. Lots of fun wasting time "escalating" the problem to countless know-nothings who of course contradict one another. Ah, yes....

 

[toofrugalformycat]

Preexisting, I feel your pain too.
Sure, you can ask the insurer about a particular instance, but in my latest case, they had just recently dropped the clinic I was referred to by my doctor. You have to check every damn time, not assume if they were in network last week, they will be this week.
As it is I chose to go with the clinic anyway because I didn't want to go back to my doctor (very busy and very expensive) just to ask for another referral, and I figured he referred me there for a reason. After going around and around with the desk staff at the clinic, perhaps they felt my pain, because my insurer reimbursed it anyway - did the clinic charge me less because I got their sympathy? It wasn't because I'm cute, believe me.
I wonder how much doctor time is wasted on re-referrals for cases like this? I didn't know he was going to refer me to someone else, so there was no way I could have checked ahead of time to see if the place he referred me was in network, or get a list of such places in network.
I am SO glad that we have this "system" of private insurers that works SO WELL and DOES NOT INTERFERE with which doctors WE CHOOSE to see. HAH! I say HAH HAH! HAH!

 

[youbet]

You have to check every damn time, not assume if they were in network last week, they will be this week.

I find this to be true, although with the internet, not much of a problem. I take 5 mins and go to my insurers web site before every doc visit, lab visit, etc. Probably wind up making a dozen or so web site visits per year. An hour well spent!

I was burned once and had to do an appeal to get paid, so now I'm dilligent about it.

It's my choice really. My insurer also offers a plan (can't remember the name) where there is no network and you can use anyone you want. But I chose to go with the PPO and the associated network of so-called preferred providers to get a lower rate. You pay your money, you take your chances!

 

[ziggy29]

Yep. It's not the provider's responsibility to tell you if they are in network. Best to confirm it with the insurer. When we go to a new provider or our doctor refers us to a lab or a specialist, we log into our insurer's web site and make sure a provider is in network before we make the appointment. Confirmation with the provider provides double assurance.

When I was in California I had the Kaiser HMO which hides just about all the nasty details of insurance -- claim forms, checking if the provider is in the network, all that stuff. We had to become educated in being health care consumers real fast when we moved.

 

[toofrugalformycat]

So I guess you're spozed to have an Iphone so you can check before you leave the doc's office, if he refers you somewhere. Maybe all doctor's offices should have a computer in the lobby for those of us Iphone-less. Assuming I'm not the only Iphone-less person left on the planet.

 

[youbet]

So I guess you're spozed to have an Iphone so you can check before you leave the doc's office, if he refers you somewhere. Maybe all doctor's offices should have a computer in the lobby for those of us Iphone-less. Assuming I'm not the only Iphone-less person left on the planet.

No.... you just call the insurer's 800 number.

I think the bottom line is that if you want the lower rates associated with PPO's and using providers the insurer has negotiated lower prices with, you need to actively work to be sure you're using network providers.

Otherwise, enroll in a plan that covers any provider. Those usually cost more and pay only to the extent that the charges are "reasonable and customary," but you don't have to worry about which providers your insurer has negotiated rates with.

Or go with a high deductible policy and pay the small stuff yourself. You'll only have to check on providers when you need something major/expensive done.

You pays yer money, you make yer choices....... It's not really that tough.

 

[toofrugalformycat]

No.... you just call the insurer's 800 number.

I think the bottom line is that if you want the lower rates associated with PPO's and using providers the insurer has negotiated lower prices with, you need to actively work to be sure you're using network providers.

Otherwise, enroll in a plan that covers any provider. Those usually cost more and pay only to the extent that the charges are "reasonable and customary," but you don't have to worry about which providers your insurer has negotiated rates with.

Or go with a high deductible policy and pay the small stuff yourself. You'll only have to check on providers when you need something major/expensive done.

You pays yer money, you make yer choices....... It's not really that tough.

Sorry, youbet, it IS tougher than that.
In the time between quitting my job, and getting my early retirement benefits which included health insurance (I am very fortunate) I chose to get private health insurance.
I was fortunate that it WAS my choice to quit rather than the many now laid off - but due to preexisting conditions (things I was BORN with, not due to bad life choices unless you count my bad judgment back when I was a primordial germ cell) I was denied coverage and had to go with the State high-risk pool. This was years ago, $600/month, $10,000 deductible for ONE PERSON. I was fortunate to be able to afford that. How many people can, realistically, especially those laid off from work?
I had NO other choices living here. If I wanted health insurance, that was the ONLY thing available to me in this State. I'm fortunate to have insurance as a retiree now, but it's that plan (with a limited choice of providers or pay the overage myself), or back to the high-risk pool which of course is even more expensive and more limited now.
Or move to Mexico or some other civilized country if they'd let me in. Or maybe some other States here in the U.S. (Wisconsin? Minnesota?), but gee whiz, is that realistic, especially for those laid off and/or broke?
I am only one of many with this situation, and I am extremely fortunate to have ANY coverage.
You pays money, but you ain't got any real choices.

 

[growing_older]

Likewise, I don't see that I have any real choice either. I'm still working, so I get my health insurance from my employer. I didn't choose the plan, in fact my employer has changed plans several times and I never had a choice - except maybe to opt out of everything, but that's such a terrible choice no one realistically takes it. It's been this way every place I worked and expect it is this way for the vast majority of employees at almost any company.

 

[Martha]

No.... you just call the insurer's 800 number.

I think the bottom line is that if you want the lower rates associated with PPO's and using providers the insurer has negotiated lower prices with, you need to actively work to be sure you're using network providers.

Even when you are sick, worried, and pressed for time.

Otherwise, enroll in a plan that covers any provider. Those usually cost more and pay only to the extent that the charges are "reasonable and customary," but you don't have to worry about which providers your insurer has negotiated rates with.

Many people have no choice of a provider. They get what their employer offered. Large employers may offer choices. Small employers rarely do. I have only one plan that I am eligible for. Just one. I have to use network providers or take a big hit.

Or go with a high deductible policy and pay the small stuff yourself. You'll only have to check on providers when you need something major/expensive done.

But as you work through your deductible the extra cost you pay by using non-network providers will not apply to the deductible.

You pays yer money, you make yer choices....... It's not really that tough.

Debatable.

 

[ziggy29]

But as you work through your deductible the extra cost you pay by using non-network providers will not apply to the deductible.

Usually, but not necessarily. I have an HDHP and HSA through my employer, and the deductible and out of pocket maximums are the same for both in-network and out-of-network.

Individual services may cost more out of network, but you'd hit the same ceiling either way.

I think that's pretty unusual, but in my plan, once you've hit the out of pocket maximums in a year there is no incentive to stay in-network. And yes, I did confirm that.

 

[youbet]

Even when you are sick, worried, and pressed for time.

I'm also in a PPO with limited choices for preferred providers and I agree not knowing where to go after you are sick is a pita. When you're sick, worried or pressed for time is not when you want to first be concerned about who your local preferred providers are. But rather than just give up (internet, paper lists, 800 numbers too complicated so give up and shoot yourself type of thing) DW and I always work hard up front to identify specialists, labs, drugs stores, etc. We also study each others plans (totally different insurers) so that if the other is incapacitated we can easily handle the paperwork, after the initial emergency is under control. Being on top of the coverage and network associated with your health insurance policy was especially important while we were raising the family, both working full time jobs and caring for a son with serious health issues (Arnold-Chiari Malformation).

I have to use network providers or take a big hit.

Me too. That's why you have to get on it and not just throw up your hands and give up. As I said in my earlier post, you have to actively work to know the providers in your insurer's network and it's best to do that apriori.