Specialist in-network, but lab isn't-How does anyone figure out all the ins and outs?
- Thread starter AbbA
- Start date
You could be right, but we know little to nothing to understand medical stuff.
Regarding your first point, the urologist didn't decide to do a biopsy because of the high PSA. The digital exam says all is fine, but still doesn't prove there is no cancer. His office sent the specimen to this Exosome Diagnostics. Once the results came back, there is some kind of cut off. When the nurse called my DH, he was told that if it's 20% or less of not sure what, biopsy is not needed. But it was 25% in his case, so biopsy was scheduled.
I did a little bit of reading about this Exosome test and like RetMD21 it seems like quite new and proprietary. The inventor/company claims that it's quite accurate. It looks for some kind of special proteins to tell whether a biopsy is needed instead of relying on PSA and digital exam. Supposedly, it's done in order to minimize the unnecessary biopsies. The 2018 medical article I read stated that this test isn't FDA cleared yet even though it sounds very promising. It immediately raised a red flag in my mind that it's not on any insurance's list. After reading this article online I kind of felt that the test was successfully promoted to urologists, and patients are guinea pigs in order to prove its potential to FDA.
This lady at the urologist's office who advised to wait for the bill from the lab itself said something strange. She said "We realize that the labs we use are not in-network, but they look for more specific ... (what?). We work together to make sure that bills are adjusted on their end". I asked for her name in case I need to discuss further, but we'll stay patient and hopefully the bills will be adjusted before the labs send them to us. I wonder 'what specific' do those labs look for... Or is this speech in order to justify their office's business relationships to their patients? Do the labs that insurances have contracts with provide mediocre quality tests because their prices are so low balled in the negotiations?
I hope you can drag it to the Medicare. How cheaper will it be to you considering premiums you'll pay and deductibles/OOP amounts you'll have at that time? It's so far for us but I hear that Medicare is also not cheap though it's probably cheaper.
On Monday I'll find out whether I need a colonoscopy or not because of anemia. I hope iron supplements I've been taking the last three months will show improvement. That's another long story since this procedure is very age restrictive.
audreyh1
Give me a museum and I'll fill it. (Picasso) Give me a forum ...
It's unfortunate. The Doctor should explain what tests he is doing and why. And if there is a new test that he feels can rule out more aggressive treatment, but that is still new and not yet covered (by anybody?), and they have made an arrangement with the lab, that should be mentioned too. It should be "I'd like to do the Exosome Diagnostics test because XYZ, but it's new so blah, blah, blah." If he is using this test frequently, this should be straightforward for him to explain. He might still not be able to tell you how much it costs, but someone in the office must be dealing with Exosome Diagnostics.
Potstickers
Recycles dryer sheets
- Joined
- Nov 19, 2015
- Messages
- 146
Personally, I like Quest and the patient portal that lets me see lab results about a week or so after the draw. Most of my docs are in practices owned by the hospital, and the hospital prefers that we use the hospital lab. I simply ask for the lab order and take it to Quest or have them fax it to the Quest location I like to use. If I was told that a test couldn't be processed by Quest, that would be an indication right then to ask about costs and coverage. Still, there are tests that are out-of-network or procedures that are not covered. My goal is to figure that out before I have the procedure. (I went and had a calcium coronary scan anyway...and glad I did.)
The urologist wants you to be happy but more importantly he doesn't want to make your primary care doctor unhappy. The company wants to maximize revenue for the test so they set the list price high anticipating that they will eventually get insurance approval for it. I think they have to be a little careful in cutting deals with individual patients. They might send you one bill and not follow up. Fwiw it looks like Medicare pays $760. The company also wants your doctor to not be discouraged by complaining patients. There are other strategies for managing elevated psa.
Link to announcement about medicare coverage: Exosome Diagnostics Announces National Medicare Reimbursement Rate Set at $760 for its Prostate Cancer IntelliScore Test | Exosome Diagnostics
Link to announcement about medicare coverage: Exosome Diagnostics Announces National Medicare Reimbursement Rate Set at $760 for its Prostate Cancer IntelliScore Test | Exosome Diagnostics
I have a hard time imagining Exsome wanting to go to court to collect. The court probably thinks that contract law does apply. The test is worth something and insurance will likely eventually cover it. I think you are caught at this awkward point in time when Exsome and the insurers are negotiating and no one is looking out for you.
aja8888
Moderator Emeritus
What's missing in the medical system is that no provider sees the patient as the customer and treats them as such.
pb4uski
Give me a museum and I'll fill it. (Picasso) Give me a forum ...
+1 That is why even though I am a financial conservative at heart I am coming around to some sort of Medicare for all approach... the current system obviously doesn't work where consumers, providers and insurers seem to have no idea what the consumer's cost of a routine procedure will be... too many cooks in the kitchen.
blueskyk
Recycles dryer sheets
The premiums for Medicare will be more than I’m paying now but my understanding (based on others experiences they have shared with me) is that it’s easier to identify what you could owe in a given situation. So, I’m hoping the provider can help me sort this out a bit.
I wish you the best on the colonoscopy/anemia situation. Medical situations are stressful enough without all the confusion about what sort of costs might be incurred.
blueskyk
Recycles dryer sheets
I’m a financial conservative myself as well - I don’t know what the answer is but it seems to me transparency about costs might be a consumer-friendly start.
Thank you for this info. Exosome submitted a claim for $795...not much of a difference, but it's good to know that we, pre-Medicare consumers, didn't get a high markup
I'm guessing it must be a very advanced test or very new or something special that drives the price here.
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'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.
Helena
Full time employment: Posting here.
- Joined
- Aug 27, 2006
- Messages
- 994
.
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.
.
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.
.
Last edited:
Potstickers
Recycles dryer sheets
- Joined
- Nov 19, 2015
- Messages
- 146
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
Give me a museum and I'll fill it. (Picasso) Give me a forum ...
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.
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.
Last edited:
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.
- Joined
- Oct 13, 2010
- Messages
- 10,763
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.
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.
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.
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.
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
.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
Recycles dryer sheets
- Joined
- Nov 19, 2015
- Messages
- 146
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.
Last edited:
Amethyst
Give me a museum and I'll fill it. (Picasso) Give me a forum ...
- Joined
- Dec 21, 2008
- Messages
- 12,683
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!
.
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
Thinks s/he gets paid by the post
- Joined
- Jul 22, 2007
- Messages
- 3,230
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.
