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

[AbbA]

Hello,

Even though we're not retired and have health insurance via workplace, I think this is the place I should ask my questions. This is an awesome forum that I've been reading over the years, so I hope more knowledgeable people can share some thoughts.

I think now I'm beginning to understand why people say that an OOP maximum doesn't mean it's an end to medical bills for a calendar year .
We've been healthy until now apparently.
Once you reach a certain age, you do blood work, and something seems off.
Primary care doc refers to a specialist.
The specialist (like the primary care doctor) is in-network.
Well, this specialist takes a different specimen and sends to a lab.
The insurance company (BSBC) processes the specialist's bill. Since we have a high-deductible plan, everything goes against the deductible first. The negotiated price barely differs from the original bill.
In regards to the lab's, at first we got a notification from BSBC that it requested more medical records or something from the provider, but it hasn't heard back.
We try to contact this lab. We left a few messages and when we caught a life person once, their IT systems were down...couldn't access the account.
Today we login to our claims on BSBC's website and see it's been 'finalized': we got no reply, the full cost is for you to pay.
We also finally manage to catch a billing person at this lab company today. She said the billing is not complete yet because she's waiting for medical records or something (who knows what). Well, then we asked "are you in-network?". Answer: No, we are not.

So, now how do you handle such situations?
How can a patient know in advance that an in-network specialist uses out of network labs?
I guess, we will need to pay the billed/retail price in full, but does it go against our deductible/OOP max or not?
Is there some kind of a negotiation tactic to ask this lab for a discount because it's not in-network and we had no knowledge of that in advance or we didn't have a choice in such a decision anyway? Full price is $800.
If out of network, can I appeal this charge with BSBC to at least apply it to our deductible/OOP max? Maybe this is a stupid question, but due to my limited understanding I think that out-of-network charges don't count towards deductible/OOP max. Am I right or wrong? If it counts, then it goes to the out-of network OOP maximum then, I'm guessing.

I lack comprehension in healthcare matters. I'm sure I'm not the first and not the last...

- How can patients know ins and outs before stepping into a specialist's office when they don't know what kind of samples will be taken out of their bodies (biopsy, urine, blood) on the spot and then sent somewhere for testing?
- You can hardly think through such details because it's already scary to be referred to a specialist.
- Even if you ask if their contracted labs are in network and get a negative answer, do I go home and contact my primary care doctor to find me a new specialist who uses labs that are in-network for our insurance plan?
- This is just mind boggling how it would be even feasible to do it when you wish to get the lab results ASAP and not life in fear for much longer.

Thank you for your help.

 

[Scuba]

I feel for you. The healthcare industry is not transparent in this regard. DH spent HOURS on the phone trying to figure out what his routine colonoscopy would cost, and whether we’d be better off paying cash or going through insurance. We also have a high deductible plan.

We finally gave up and just decided to run it through insurance. It’s crazy how there are multiple providers involved (doc, facility, labs, etc.) and NO ONE coordinates the total cost and various options available to you.

If I were in your situation, I’d complain to your insurance provider as well as try to negotiate with the lab to take a cash payment instead which might be less than your insurance company out of network rate. Good luck.

 

[pjm-7]

When I was working I was caught in the same situation, doctor in network lab out. The insurance company told me I needed to pay the entire bill. One call to company's benefit office cleared that up. The insurance must pay the lab at the in-network rate since the main provider was in-network. Call your benefits office.

 

[John Galt III]

Abba, Whenever I think there might be a lab involved when I go to see a specialist, I ask the specialist's office what labs they use and then I call my insurance co to verify that the labs are in network. Another annoying thing is that if you ask the ins co if something is 'covered', they'll say 'yes' and you think you're good. Then you get the bill and yes, indeed, it is 'covered', but only if you have already reached your $6,700 annual deductible (which, of course, they never tell you, unless you know to ask). So you are left paying for the entire 'covered' item. Sort of like, yes, it's covered but it's all paid for by the patient. Arghhh....

 

[pb4uski]

..... Another annoying thing is that if you ask the ins co if something is 'covered', they'll say 'yes' and you think you're good. Then you get the bill and yes, indeed, it is 'covered', but only if you have already reached your $6,700 annual deductible (which, of course, they never tell you, unless you know to ask). So you are left paying for the entire 'covered' item. Sort of like, yes, it's covered but it's all paid for by the patient. Arghhh....

WADR, that problem is your misunderstanding of how health insurance works.... other than certain specified well care, you pay all charges at the negotiated rates until the deductible is met... then the insurance pays.... pretty elementary.

Your collision on your car insurance works the same way.. you pay the deductible and then the insurance kicks in.

 

[AbbA]

Thanks for the replies.
Y'all saying that I've suspected: it's a cat and a mouse game, and the mouse (the consumer) will mostly always lose.

We might try to call the benefits department, but that could be another issue. In the past, companies used to have their own benefits departments. Nowadays, HR/benefit/payroll departments are outsourced which means it's great for the company's bottom line, but not so much for the company's employees because outsourced staff knows much less than the company's staff. And how would they help me? Call BSBC to tell them that we qualify for the in-network pricing?
How would BSBC determine what price of this out-of-network lab satisfy 'in-network' cost that we should be pay? We haven't reached out high deductible yet.
Would that mean that we'd pay the 'in-network' price and BSBC pay the difference in this case?
We might try this but it could also worthless waste of time/energy/frustration in order to save perhaps $100-200.

The way I'm seeing healthcare business working in the USA, it's like mafia, but it's all legal and democratic supposedly.

 

[AbbA]

Abba, Whenever I think there might be a lab involved when I go to see a specialist, I ask the specialist's office what labs they use and then I call my insurance co to verify that the labs are in network.

Yes, that's an option to do it, but then what do you do if it's not in-network?
Call the nurse of the primary doctor and ask for the next specialist and refer me there? Then call the new one and their labs? And so you go down the list? Isn't this insane how many hours you'd spend calling and not working? Another thing is one lives in a small town...there might be a limit of those specialists.

But anyway, in our case, we didn't even suspect that the specimen would be sent to an outside lab. We thought it was just an usual analysis done on the premises. This was supposedly done as another additional step in order to determine if a biopsy is needed.

 

[Just_Steve]

Whenever I have labs done I tell them Labcorp or Quest only, they are the only two my plan takes. No provider has ever gone against my direction.

 

[zinger1457]

Even when using in network labs you can still run into issues if the billing code used is incorrect. It's happened to me a couple times, should have been bill coded as preventative but was coded as diagnostic so it goes against the deductible. Contact the doctors office and they say it's the labs problem, contact the lab and they say it's the doctors problem. Both times the amount was small so just ended up paying it, wasn't worth my time and effort.

 

[pb4uski]

It is a frustrating process. My position with the lab would be that I would not pay anymore than the insurer's negotiated rate.... or perhaps 120% of the insurer's negotiated rate for such service... once I get the bill from the lab if it is more than that I would call them, explain the situation and offer to settle it then and there by credit card for that amount... if they refuse then send me a bill but don't hold your breath for payment... if the rep refuses ask to speak to a manager who might have authority to make a deal.... I suspect that they'll see that immediate payment of a reasonable amount is better than chasing you down for an outrageous amount but YMMV.

 

[John Galt III]

WADR, that problem is your misunderstanding of how health insurance works.... other than certain specified well care, you pay all charges at the negotiated rates until the deductible is met... then the insurance pays.... pretty elementary.

Your collision on your car insurance works the same way.. you pay the deductible and then the insurance kicks in.

Nope. I have not met my deductible yet this year, and my optometrist visit (the visit itself, not the retinal photography) was paid for at 100% of the allowed amount of $105. I paid for none of the 'office visit'. I did pay for the photography, and that amount was applied toward my annual deductible.

 

[John Galt III]

Yes, that's an option to do it, but then what do you do if it's not in-network?
Call the nurse of the primary doctor and ask for the next specialist and refer me there? Then call the new one and their labs? And so you go down the list? Isn't this insane how many hours you'd spend calling and not working? Another thing is one lives in a small town...there might be a limit of those specialists.

But anyway, in our case, we didn't even suspect that the specimen would be sent to an outside lab. We thought it was just an usual analysis done on the premises. This was supposedly done as another additional step in order to determine if a biopsy is needed.

Yes, if the specialist does not use any in-network lab, I would definitely ask for a different specialist. I don't have to have a referral, with my PPO insurance, fortunately, so I would just call the ins co and ask what specialists are in network near me. The specialists always (it seems) send the samples out to an external lab, anyway. Never had one do an on-site lab test. And yes, I waste a lot of time on the phone making sure everything is in network. It's awful. If you get an xray on premises while visiting a specialist you have to verify the xray machine is part of the specialist's practice, and not some other business entity entirely, which may be out of network. And no one warns you about it, you have to take the initiative and be proactive, as well as pay your monthly premium. Arghhh....

 

[pb4uski]

.... Another annoying thing is that if you ask the ins co if something is 'covered', they'll say 'yes' and you think you're good. Then you get the bill and yes, indeed, it is 'covered', but only if you have already reached your $6,700 annual deductible (which, of course, they never tell you, unless you know to ask). So you are left paying for the entire 'covered' item. Sort of like, yes, it's covered but it's all paid for by the patient. Arghhh....

WADR, that problem is your misunderstanding of how health insurance works.... other than certain specified well care, you pay all charges at the negotiated rates until the deductible is met... then the insurance pays.... pretty elementary.

Your collision on your car insurance works the same way.. you pay the deductible and then the insurance kicks in.

Nope. I have not met my deductible yet this year, and my optometrist visit (the visit itself, not the retinal photography) was paid for at 100% of the allowed amount of $105. I paid for none of the 'office visit'. I did pay for the photography, and that amount was applied toward my annual deductible.

It sounds like the optometrist visit was covered not subject to the deductible, like other wellness visits.

Under most policies, wellness is not subject to deductibles but services other than wellness are. For example, my annual physical is covered and not subject to the deductible.... if I have tests that are done that are not part of the annual physical they would be subject to the deductible.

 

[RetMD21]

If it is a blood test I would be inclined to ask for the slip and take it to Quest or whichever lab is in network. The specialist in unlikely to care.

I had to give the doctor's office biller the correct diagnostic code for a bone density screening. The insurer wouldn't tell me the correct one but they did tell me that the one the office used was wrong.

 

[MichaelB]

WADR, that problem is your misunderstanding of how health insurance works.... other than certain specified well care, you pay all covered charges at the negotiated rates until the deductible is met... then the insurance pays.... pretty elementary.

Your collision on your car insurance works the same way.. you pay the deductible and then the insurance kicks in.

A minor addition.

So, now how do you handle such situations?

Don’t give up just yet. There may be a legitimate reason the physician used another lab. That is, a reason that would be acceptable to the insurer.

I would contact the physician and request an explanation, making it clear the out of network charge is a financial burden. If the lab performed a test or analysis not typically done by the network labs, you have reason to dispute the denial by BCBS.

The BCBS network tends to be broad, so if the lab performed routine tests, the physician should explain why an atypical lab was used in place of a common network lab. If the lab chosen by the physician doesn’t take insurance, I would file a complaint against the physician with the state regulatory board and the Attorney General.

Was the test / specimen produced at the lab location, or was it provided to the physician’s office for their handling with the lab? Also, are you certain the test itself is covered by insurance?

 

[AbbA]

A minor addition.

Don’t give up just yet. There may be a legitimate reason the physician used another lab. That is, a reason that would be acceptable to the insurer.

I would contact the physician and request an explanation, making it clear the out of network charge is a financial burden. If the lab performed a test or analysis not typically done by the network labs, you have reason to dispute the denial by BCBS.

The BCBS network tends to be broad, so if the lab performed routine tests, the physician should explain why an atypical lab was used in place of a common network lab. If the lab chosen by the physician doesn’t take insurance, I would file a complaint against the physician with the state regulatory board and the Attorney General.

Was the test / specimen produced at the lab location, or was it provided to the physician’s office for their handling with the lab? Also, are you certain the test itself is covered by insurance?

The specimen was taken at the specialist's office (urologist). This is how the whole thing went:
- The review of blood work at the primary care doctor says elevated PSA. Go see an urologist;
- The nurse at the urologist's office takes a specimen;
- The urologist does a digital exam (it's good so far, no lumps or bumps);
- Urinalysis doesn't find prostatitis;
- Just before leaving the doctor says "We'll look into it further. We'll send the sample to the lab and will be in touch in 3 weeks";
- Get a call from the nurse: "The results showed that it's above the cut off and recommend biopsy" ... it's scary, but waiting for its results.
- Get a letter from BSBC saying that they got a claim, they requested for more info, but nobody responds. That's when we called BSBC to find out about the provider...Exosome Diagnostics (definitely not part of the urologist's office). After doing some reading online, finally figured out that this must be a lab that does advanced type of tests to find the markers more accurately that tells the doc whether a biopsy is needed or not.
- The next time we check claims on BSBC, it says 'finalized', but when you open the PDF file it shows the billed amount, amount against deductible, and subscriber responsibility. The same retail price in all columns. It's blank under "allowed amount" (aka 'negotiated price').
- Finally one of us manage to chase down billing dept. of this lab and learn that the lab is not in the network, but also added that it's not processed and it takes time.
- Not seeing the 'allowed amount' on the EOB triggered questions that we should qualify for some kind of discount and hence my coming here for team brainstorm on how to proceed/handle this.
- Hopefully it will not be the same story with the lab that performs pathology.

 

[swakyaby]

When DH received a surprise lab bill of over $1,000 for a single blood test from an independent lab, I called the Dr's office and said I (as the insured subscriber) did not agree to this test, did not agree to out-of-network lab, and it was not disclosed to me that an out-of-network lab was to be used. The odd response from the office manager was that I should simply refuse to pay the bill and say I couldn't afford it.

Instead, I returned a copy of the bill to the lab accompanied by a letter that repeated the above: that I did not consent to this going to an out-of-network lab, and I was not informed of this. Surprisingly, I never heard from the lab again.

 

[MichaelB]

The specimen was taken at the specialist's office (urologist). This is how the whole thing went:
- The review of blood work at the primary care doctor says elevated PSA. Go see an urologist;
- The nurse at the urologist's office takes a specimen;
- The urologist does a digital exam (it's good so far, no lumps or bumps);
- Urinalysis doesn't find prostatitis;
- Just before leaving the doctor says "We'll look into it further. We'll send the sample to the lab and will be in touch in 3 weeks";
- Get a call from the nurse: "The results showed that it's above the cut off and recommend biopsy" ... it's scary, but waiting for its results.
- Get a letter from BSBC saying that they got a claim, they requested for more info, but nobody responds. That's when we called BSBC to find out about the provider...Exosome Diagnostics (definitely not part of the urologist's office). After doing some reading online, finally figured out that this must be a lab that does advanced type of tests to find the markers more accurately that tells the doc whether a biopsy is needed or not.
- The next time we check claims on BSBC, it says 'finalized', but when you open the PDF file it shows the billed amount, amount against deductible, and subscriber responsibility. The same retail price in all columns. It's blank under "allowed amount" (aka 'negotiated price').
- Finally one of us manage to chase down billing dept. of this lab and learn that the lab is not in the network, but also added that it's not processed and it takes time.
- Not seeing the 'allowed amount' on the EOB triggered questions that we should qualify for some kind of discount and hence my coming here for team brainstorm on how to proceed/handle this.
- Hopefully it will not be the same story with the lab that performs pathology.

No expert here, but this could be a test that is legitimate, but recent enough that insurers don’t yet cover it. They often have to be pushed, kicking and screaming, into agreeing to cover some procedures.

If that’s the case, you should consider disputing the ruling with the insurer, and if they decline, filing a complaint with the state insurance regulator. If the test is “medically necessary” in the judgement of the physician, it should be covered by the insurance policy.

Regardless, you might consider, during your next visit to the specialist, letting him know he really needs to be clear and upfront with a patient about the possibility of no insurance coverage for this type of test. Might not help your case, but it might help the next patient walking through the front door.

 

[RetMD21]

Usually if the test isn't allowed there isn't a negotiated discount between the insurer and the testing company so you are stuck with the list price.

I know that you don't have medicare but for a medicare beneficiary if you re going to bill them for an non-covered service you have to notify them in advance.

You can ask/insist that the biopsies go to an in-network lab.

 

[AbbA]

Thank you so much for sharing your thoughts how you would approach such a situation as ours. I would like to give an update...will be long and probably show how sill all is. If you are not aware of everything in advance, you ask silly questions and it's impossible to know in advance because the parties who should help you (doc offices, insurance) appear to keep some kind of secrets assuming that patients know everything beforehand how to resolve their questions. It's an evil circular circumstance...

First, I called the billing of Exosome Diagnostics 2 days to tell them that the claim appeared closed at our insurer but clearly not completely processed due to the missing med.records that BSBC had requested. The biller told me that she never got such a request and provided a fax # when I said I'd follow up with BCBS.
As soon as I hang up, I call BCBS and get a 'gatekeeper' so to speak.
I tell her about the finalized claim that doesn't seem finalized to me.
She reviews it and says to me "Since this is out of network, and you have a high deductible, you're on the hook".
Well, yeah, but we were not told about the test and didn't have a clue about this 'out-of-network' vendor until we got this (freaking) bill.
She goes "you can look up who's in network or not on our website".
I go "Can you tell me how it plays out in the real world? I take a laptop along to a doctor. I ask what labs they use (btw, I even don't know that a test will be done until I'm almost out of the patient's room). I fire up a laptop right there and start looking up what BCBS covers. Is that right?"
She goes "You can look up. BSBC has contracts with Quest and Labcorp"... I'm thinking "yeah, sure." I almost started laughing how ridiculous this sounds.
So, then I ask her: Could I find out how much such a test would have cost at the in-network lab?
No, you cannot because I don't have a pricing sheet.
But wouldn't you know based on the code of this claim?
No, I don't know because this is out of network vendor.
Hmm, so what kind of procedure was this claim for?
It's for 'prostate non-preventive'
OK, so how much this thing prostate non-preventive cost at Quest.
I don't know without the pricing sheet.
Who has this pricing sheet?
Claims.
Can you give me a phone # or transfer me there?
No, there is no phone # to claims. You can to talk to us only.
Ahh, OK, so you're the gatekeeper. Well, OK, can you at least add this fax # I was given and reopen the claim? When can I follow up on this?
Well, yeah, I can add it, but I don't know why. You're on the hook for the whole thing. I can try sending back to the claims...
I got an impression, that there was no point doing this, but my worry was this this bill will be stuck somewhere.

Yesterday I tag along to the urologist's office because I'm worried too and want to hear the diagnosis and ask questions. The great news in this whole thing is that no cancer was found. The doc thinks that the elevated PSA was a fluke and expects to be down next time. Therefore DH needs to go back in December to draw blood. Fingers crossed on that or otherwise there would be a need for MRI type of test to access the area of prostate that biopsy is incapable of reaching. This time I make sure to ask that this blood test will be done locally.
While checking out we were lucky that an office manager was training somebody and she overheard my question of where the biopsy was done.
So, neither the first test nor biopsy was done in-network
This more knowledgeable lady said that apparently they aware of this situation. She advised to ignore EOB and wait for the actual bill from the lab. Supposedly, we should see an adjustment and it should be lower. For now, we need to wait. We wish somebody has warned about this in the urologist's office. Of course, we will never know how much it would have cost us if the tests were done in network. Maybe we could call the Labcorp or Quest to inquire, but that would retail prices, not the negotiated prices.

We feel so relieved that diagnosis was in our favor that the situation with these out-of-network bills doesn't sound that awful. But OTOH, I've gotten my first taste on how the healthcare works in this country. My feelings would have turned out to be very resentful against this apparently secretive and manipulative pushing and pulling in the corridors of the healthcare had we heard a bad diagnosis...

PS. the blood pressure was kind of high, but hopefully, it was because of feeling the stress before the doctor came and gave good news.

Thanks for listening to my rant

 

[RetMD21]

Maybe we could call the Labcorp or Quest to inquire, but that would retail prices, not the negotiated prices.

We feel so relieved that diagnosis was in our favor that the situation with these out-of-network bills doesn't sound that awful. But OTOH, I've gotten my first taste on how the healthcare works in this country. My feelings would have turned out to be very resentful against this apparently secretive and manipulative pushing and pulling in the corridors of the healthcare had we heard a bad diagnosis...



Thanks for listening to my rant

I wouldn't necessarily pay the bill right away. This is a new nonstandard proprietary single source test so it doesn't matter if if went to Quest first or some other lab. Usually the company is trying to get it on the approved list and they tell the doctors not to worry about the cost because they have patient assistance programs. The company really doesn't want to lose your doctor so you have some leverage. I would complain to his office regardless of the outcome.

The usual thing for elevated repeat psa is to just repeat which is where you have ended up.

 

[target2019]

A couple of observations.
1) Biopsy based on one high PSA test is kinda stupid.
2) Biopsy that does not find cancer means that the sample did not find cancer.
Glad to hear everything looks promising.

 

[blueskyk]

The system is really a nightmare when it comes to finding out costs. It peeves me when anyone declares that consumers need to exercise due diligence in order to estimate and “shop around” for the best deal because, as noted here and in other medical cost related threads, it’s an iterative, Sysiphusian task. I’m in awe of the post describing the back and forth with all the parties- and still no answer. Honestly, it wouldn’t take much to make the process a Saturday Night Live skit. Or maybe a rendition of The Three Stooges, “Who’s on first?”

Yesterday I went in to see about getting what appears to be a ganglion cyst removed from my finger. When I met with the surgical scheduler, I said I had a high deductible plan and was trying to understand the costs. She gave me the CPT code and a “special number” for the insurance person (I’m not intellectually lazy and generally enjoy learning new things but why should I ever need to be well versed in medical billing codes?). After finding out just the hospital charge alone was $5700 for a 90 min outpatient surgical adventure, I began pondering the potential for surprises in out of network charges (having been bitten by this in the past) and called back and said, “Would it be okay to put me on the schedule for a year from now when I’m on Medicare?”

The dr said “these things don’t generally turn out to be cancerous” so if he recommends the removal of the cyst be sooner than Medicare, I’ll then begin researching the uninsured cash price. At least now I have the CPT code.

What a CRAZY system!

 

[Chuckanut]

This happened to an acquaintance. Every year she goes to the same Woman's Health Center for the same test. A few years ago, her insurance rejected the claim on the grounds that it was 'experimental'. Apparently, the Center changed something in how they did the test. But, the patient has no knowledge of this beforehand, and is truly collateral damage in the fight between the care giver and the insurance company.

 

[blueskyk]

I have one last thought on dealing with medical cost estimating and Bill error fixing. First a short story. Not sure how well this translates to people not familiar with horses, but here goes.

I used to ride horses with a woman who rode a mule who had a nasty habit of rearing when he was young. She took him to a trainer who suggested that when he reared, she should take the end of her reins (she had the really long western style ones) and whack him on the sheath (penis for those not familiar with horse terminology) while she was on his back and rearing.

She dismounted, handed him the reins and said, “Show me.”

And that’s what I want to say when anyone acts as if this is a straightforward process - show me.