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

[AbbA]

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]

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]

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]

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]

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]

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]

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

 

[RetMD21]

I think this expensive test was probably worthwhile. If not for the test, a more expensive, invasive and potentially dangerous biopsy would have been done. Based on the test it wasn't needed. It really has nothing to do with in or out of network. The urologist could have done a better job communicating.

 

[audreyh1]

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.

Really? Had no idea! As long as no veto, will then go into effect Jan 1 2020.