Insurance denial, doctor already performed tests, stuck with $3000 charge

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I went to a neurologist; he told me that for Fronto Temporal Demensia, I need to do a gene test. He verbally  told me that he is getting an approval. This happened in June.  He took a blood sample in June and apparently sent it for the test in June. I did not know if he got the approval or not.  Today I get denial letter from insurance stating that the test is not necessary. I see in my Claims page that the cost of the test is $3500.  What is my recourse ? My insurance is Blue Cross Anthem.

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Something tells me that either that doctor has a stake in that lab through his wife or a nephew, or even a stranger who ... (more)

Rubl (Sep. 22, 2016 @ 3:36p) |

In this case the only difference would be the doctor wouldn't have ordered the test in the first place.

LorenPechtel (Sep. 22, 2016 @ 5:50p) |

That crossed my rather cynical mind when I first read this thread.  The whole situation sounds a bit bizarre to me.

OP:  ... (more)

Mickie3 (Sep. 22, 2016 @ 7:43p) |

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Doctor: "Hello patient! I'd like to perform this test."
Patient: "Interesting thought, doctor. Since I have PPO insurance, can you or an employee of your office provide me the billing code of this test, that I might call my insurance and see if it's covered?"
Doctor: "While certainly, patient. Let me find that information for you."

Patient: "Hello PPO provider, is <billing code> covered by you?"
Agent: "I'm afraid we do not cover that billing code."
Patient: "That sucks, but I'm glad I called so I didn't get stuck with a huge bill because my doctor is not responsible for ensuring insurance eligibility for procedures!"
 

There really ought to be a better system for non-emergency visits and procedures. Like waiting for insurance to pay before conducting the procedure. Or an agreement for the price 'not to exceed' X before proceeding. The providers basically put all the risk on the patients.

Although in this case, it wasn't a dispute over price but the medical necessity of the test.

So it was a test to see whether or not the patient had a mental disability, and yet the patient was responsible for negotiating the process of determining eligibility? If the patient is able to avoid paying cash, he probably doesn't have the disease. If the op's test came back positive, the OP should pay the doctor with a heaping plate of peanut butter and shoelaces.

 
Lomic said:   Doctor: "Hello patient! I'd like to perform this test."
Patient: "Interesting thought, doctor. Since I have PPO insurance, can you or an employee of your office provide me the billing code of this test, that I might call my insurance and see if it's covered?"
Doctor: "While certainly, patient. Let me find that information for you."

Patient: "Hello PPO provider, is <billing code> covered by you?"
Agent: "I'm afraid we do not cover that billing code."
Patient: "That sucks, but I'm glad I called so I didn't get stuck with a huge bill because my doctor is not responsible for ensuring insurance eligibility for procedures!"

  
I don't know about where you live, but where I live, this is a nigh-impossible task.  I have tried this approach before, a few times, and entirely without success. 

For starters, the providers who order the services are usually detached from what will be billed.  They just check a box on their 'services performed' sheet, check the appropriate box on a screen, or submit an order for tests to be performed.   In many cases this doesn't even reveal what CPT codes (which indicate a specific procedure) will be submitted to the insurer.  And it certainly doesn't have a price specified alongside it.  If you contact the billing department, normally they aren't allowed to reveal dollar amounts, even if CPT codes can be nailed down in advance.

In the case of genetic, blood, tissue, or urine testing, it's not at all unusual for an outside party to be involved.  That could be a 3rd-party lab, a doctor you've never heard of interpreting the results, or any number of other things.  Good luck finding out in advance whether this person and/or facilities are considered "in network."    And if it turns out they're not, then with many plans (HMOs in particular), you're entirely screwed, as "out of network" providers are not covered at all.  At a minimum, 'out of network' deductibles and out-of-pocket maximums come into play.  Even something as simple as your doctor having a radiologist or 2nd doctor evaluate an x-ray may result in this problem!

And even if you DO try to plan ahead to determine the cost of something, and you succeed, the insurance company may elect (at their sole discretion)  to "rebundle" the CPT codes and refuse to pay, anyway.  United Healthcare is particularly evil in this regard, although they are FAR from the only company that pulls this.  They may also claim a procedure is covered for certain ICD codes (codes that indicate the diagnosis), but then not for other ICD codes.  Which diagnoses result in the procedure being covered, and which ones don't qualify, is "internal knowledge" the insurance company will not share with anybody outside their walls.

Your medical provider and their billing department won't know beforehand if this is going to happen, even if they wanted to .help you avoid the problem.  And if it the insurance company stiffs you, good luck pursuing relief.  Usually you're stuck with internal review (not even arbitration!).  Guess who they're going to side with?   Your best case scenario at that point is to fight, which will cost you many hours of your time, and a ton of frustration (been there, done that!).   And you will almost certainly still lose.  If you have insurance, and use health care, YOU ARE AT RISK for this happening to you.   No two ways about it.

These and other strategies are all just part of an insurance company's book of sneaky tricks, the goal of which is to avoid paying whenever possible.  Make no mistake: They are not there to keep you healthy and/or alive.  They are there to MAKE MONEY. 

I'm a responsible adult, and more than happy to do my due diligence.  On a number of occasions, I wanted to do something to save the insurance company AND me both some money, but was stymied.  You might say I'm the "smart healthcare consumer" all the insurance companies CLAIM they want people to become, in order to help control costs and avoid unnecessary expenses.   I would truly be thrilled, if only it was as simple as checking prices, shopping around, and using good discretion.  But in reality, it's not this simple.

Even with the ACA, health Insurance in the USA continues to be an completely opaque game designed to entirely favor the house.


EDIT: Previously said NDC codes when I meant ICD codes.  Corrected myself.  Also added comment about time & frustration.

TravelerMSY said:   There really ought to be a better system for non-emergency visits and procedures. Like waiting for insurance to pay before conducting the procedure. Or an agreement for the price 'not to exceed' X before proceeding. The providers basically put all the risk on the patients.

Although in this case, it wasn't a dispute over price but the medical necessity of the test.


As I recall, earlier drafts of the Affordable Care Act included price-disclosure measures, which were subsequently removed.
Guess whose lobbyists made sure THAT happened?

 

Ask doc to refile under a different CPT code, or give doc written consent to appeal on your behalf.

https://www.anthem.com/wps/portal/ahpprovider?content_path=provi...
If you request an Appeal on behalf of a Covered Individual, written consent from the Covered Individual is required except when an expedited review is necessary.

Were the results positive? If so, then to me it would seem the test was needed.

lonestarguy said:   Were the results positive? If so, then to me it would seem the test was needed.
  
They're more interested in denying whatever they can.

A few years ago my wife got a bogus denial because someone put the wrong date on the authorization.  We were still fighting that when they had already paid for treatment of what they found.

While we have no idea whose mistake it was it clearly could not have been my wife as she was sitting on a exam table for the whole time involved.

Lomic said:   Doctor: "Hello patient! I'd like to perform this test."
Patient: "Interesting thought, doctor. Since I have PPO insurance, can you or an employee of your office provide me the billing code of this test, that I might call my insurance and see if it's covered?"
Doctor: "While certainly, patient. Let me find that information for you."

Patient: "Hello PPO provider, is <billing code> covered by you?"
Agent: "I'm afraid we do not cover that billing code."
Patient: "That sucks, but I'm glad I called so I didn't get stuck with a huge bill because my doctor is not responsible for ensuring insurance eligibility for procedures!"

  

Vox actually had a whole video about how that's impossible:

https://www.youtube.com/watch?v=Tct38KwROdw



 

Call the lab and negotiate a cash discount.

Provider needs to prove that a procedure is medically necessary. If your doctor cannot provide that, they performed an unnecessary procedure, therefore you should not be liable for it.

I'd call the doctors office first and ask them about it.
Its possible the doctor didn't clear it but maybe just verified that you have insurance.
Its possible it was coded wrong or theres just a mistake.
Its possible the doctor has valid reason to believe its medically warranted and the insurance company may need convincing. In that situation the doctor may be your ally in arguing for coverage with the insurer.

voonli said:   Provider needs to prove that a procedure is medically necessary. If your doctor cannot provide that, they performed an unnecessary procedure, therefore you should not be liable for it.
  
Yup - you should establish what other things were done first before getting to the expensive test. Was this a in-network or out-of-network? If in-network, you can file with the governing body to say that you went to an "anthem approved doctor".  BTW, Anthem sucks but don't know if Cigna is any better.

Hmmm, whenever I have had questionable (non-emergency) procedure I would ask the doctor to submit for PRE-AUTHORIZATION. The ins co will send (in writing) the equivalent of an EOB. Showing what is or is not covered. Then there is no question assuming the doctor submits the procedure under the same codes he will when the procedure is completed.

A quick google search shows genetic testing for frontotemporal dementia is not covered by Anthem at all--it is considered purely investigational by them. I would see if you can appeal but you might be out of luck. I would definitely call the doctor--if he verbally agreed to get prior authorization, the least he could have done is have his staff spend 5 minutes doing some research. In my practice, if I order an unusual test for a patient, I'm going to make at least some minimal effort to check their coverage. Yikes, your patient has a pending dementia diagnosis and you want him to figure out his insurance coverage?

Anthem

I'm really sorry that you might have a dementia diagnosis and hope things work out for you and your family.

From the link that Herb gave.:

"There is no clear difference in the management of an individual with suspected or genetically confirmed FTD"

It makes sense that the insurance doesn't cover it in that case. Assuming that is that the medical community agrees with this.

jerosen said:   From the link that Herb gave.:

"There is no clear difference in the management of an individual with suspected or genetically confirmed FTD "

It makes sense that the insurance doesn't cover it in that case. Assuming that is that the medical community agrees with this.

  
This.  Insurance is not the business of providing you with a diagnosis.  They're in the business of providing health care.  In their world a diagnosis is only a means of deciding on treatment, any diagnosis which does nothing to decide treatment is of no value and not worth spending any money on.

If there is a suspicion that the patient has this particular medical issue, it just seems so unfair that the same patient is expected to navigate the complicated world of health insurance, approvals, billing, etc., on top of just trying to get the initial medical diagnosis in the first place, and to get whatever treatment there might be for it.

-----
Here is some information showing the currently-known genetic connections with frontotemporal degeneration: http://www.theaftd.org/understandingftd/genetics 

The independent patients' association which runs that website might be able to give you some information about insurance coverage of the gene test - maybe a few of their members have been able to appeal the initial denial, and get it paid for.

---
"The diagnosis of frontotemporal degeneration generally involves:
•Medical history and detailed neurological examination.
•Neuropsychological examination to assess language, behavior, memory, executive and visual-spatial functions.
•Neuroimaging to determine where and how extensively brain regions have atrophied, or may be experiencing decreased blood flow. Some of these neuroimaging studies are: MRI (magnetic resonance imaging), PET (positron emission tomography), and SPECT (single photon emission computed tomography)."
http://www.theaftd.org/understandingftd/diagnosis 

That source says that genetic testing is just a research area, and not a typical method of diagnosis for this health problem.

---
Here is some more technical information:
http://memory.ucsf.edu/ftd/overview/biology/genetics/multiple/ft... 

UCSF says: "Genetic testing is usually coordinated through a genetic counselor or other genetics professional following a genetic counseling appointment and detailed three-generation pedigree."

Did you go through a genetic counselor to get the genetic test?

If not, I wonder if the neurologist was following standard procedures for diagnosing this particular medical problem (I have no idea if he/she was or not).  That might be something that you can look into more, if you need to (if he didn't follow the normal procedures to test/diagnose you).

----
If the doctor specifically told you at the appointment that he would get an approval, but didn't, and now you are being sent the bill, if I were you, I would:

Call the doctor's office and ask about the bill politely -- act like it must have been a bureaucratic error on the part of the insurance company, because the doctor had told you he was going to get an approval for the test.
See what the doctor's office says. They might say that they will re-submit the bill with a different code or something, or maybe they honestly did get approval and it really was the fault of the insurance company for not noticing (that can happen sometimes).  

From now on, TAKE NOTES about everything the doctor's office tells you about this bill, what they say about the doctor's promising to get the approval, everything. Write down the names of the people you talk to, and the dates of the phone calls.

Do the same with the insurance company -- write down names, dates, contents of every phone call, who said what. Ask for confirmation in writing of important things.

Maybe there was a medically-necessary reason the doctor did this test, maybe there is a way to get it paid for by the insurance.

After talking to the doctor's office and seeing what they will do, how they will try to solve this issue, let them do whatever they will offer to do, to handle it.

If they won't help you, then you could call the insurance company, explain the situation, ask for their help.

If it's not black and white (although it sounds from what the commenting MD wrote above that Anthem says they absolutely do not cover this test), you could also officially appeal the insurance company's decision - sometimes those appeals do work, and the customer wins (I have won some official appeals against my insurance companies' initial denials).

Try those things first, but if none of that works, you could talk to the lab that is billing you, explain the unexpected situation that has landed in your lap, and ask if there is a cash/out-of-pocket rate for the test. Sometimes they will give you a big discount if you fully pay a special, lowered rate on that same day or within a few days, something like that.

Will you be going back to that doctor?  It sounds like he's not the most careful person (or maybe there was simply a bureaucratic mistake with this).

---
Good luck to you -- I am sorry to hear that there is a suspicion that you or a family member might have this illness.

My wife comes from a developing country where medical services are cash & carry.  There is no billing.  They don't care where you live or if you have a government ID number or not.  Prices are up front.  If a general doctor wants you to have a special test up on the 2nd floor of the hospital, you go up to the second floor and the specialist will tell you the price and if you want to pay it, you pay and they do it.

Very minimal overhead.  Office buildings filled with staff are eliminated.  The price is less, so there are medical tourists.

http://universityhealthnews.com/daily/memory/ketogenic-diet-show...
The sooner you start ... the better. (if it helps and i have no idea if it does)

JiggleTheHandle said:   My wife comes from a developing country where medical services are cash & carry.  There is no billing.  They don't care where you live or if you have a government ID number or not.  Prices are up front.  If a general doctor wants you to have a special test up on the 2nd floor of the hospital, you go up to the second floor and the specialist will tell you the price and if you want to pay it, you pay and they do it.

Very minimal overhead.  Office buildings filled with staff are eliminated.  The price is less, so there are medical tourists.

  
I was visiting a friend in Ensenada (not living in the American expat area) and it was interesting the one time they went in for something minor at the neighborhood clinic.  There was a clear price list at the entrance with everything from having a nurse administer a shot to a consultation with the doctor.  The most expensive item was less than $20 or so, it was literally in a converted house with a staff of 2, three at most in the middle of a subdivision.

He had to spend a week in the hospital and the total price was around $1000 or so.

Also a lot of medications are over the counter there that are prescription here, particularly things that are "quality of life" like Hormone/testosterone and Viagra. 

RedWolfe01 said:   
JiggleTheHandle said:   My wife comes from a developing country where medical services are cash & carry.  There is no billing.  They don't care where you live or if you have a government ID number or not.  Prices are up front.  If a general doctor wants you to have a special test up on the 2nd floor of the hospital, you go up to the second floor and the specialist will tell you the price and if you want to pay it, you pay and they do it.

Very minimal overhead.  Office buildings filled with staff are eliminated.  The price is less, so there are medical tourists.

  
I was visiting a friend in Ensenada (not living in the American expat area) and it was interesting the one time they went in for something minor at the neighborhood clinic.  There was a clear price list at the entrance with everything from having a nurse administer a shot to a consultation with the doctor.  The most expensive item was less than $20 or so, it was literally in a converted house with a staff of 2, three at most in the middle of a subdivision.

He had to spend a week in the hospital and the total price was around $1000 or so.

Also a lot of medications are over the counter there that are prescription here, particularly things that are "quality of life" like Hormone/testosterone and Viagra. 


Don't understand what points some of you are making with regards to prices. Everything is relative. An engineer in US makes a lot more in salary than an engineer in Ensenada. You like the Ensenada medical system, accept the Ensenada wages for yourself and then we will talk. I also suspect that the Ensenada doctor probably just disappears to some other place if he does something wrong versus facing a huge malpractice suit in the US.

We were traveling in Europe and some of the local train stations were not designed for handicapped access. I am not handicapped but it was a real pain to lug the suitcases across a flight of stairs. In US, you hardly have such an issue since all business entity must provide for handicapped access. So who pays for that? Try paying out for all such regulations/insurance premiums/higher standard of living etc. all out of the $1,000 hospital visit.

The point is price disclosure up front vs. an opaque mess.

A lot of this could be avoided by cranking up the deductibles and HSA limits. On average, the cheaper premiums should more than cover any costs like these.

Zaos said:   The point is price disclosure up front vs. an opaque mess.

A lot of this could be avoided by cranking up the deductibles and HSA limits. On average, the cheaper premiums should more than cover any costs like these.

  

Huh?  And how would you do that?

The test in this case isn't a proven test and just because the neuro likes it doesn't really mean squat to the insurance carrier.  Its excluded by the policy, just like most other procedures, drugs, etc. that are considered "experimental" are.  Its not like its not disclosed when you buy the policy.



 

Your mistake was to allow your MD to send your blood elsewhere for work.  You should have asked for a req. form and for you to have gone to a lab of your choice.

It is possible to obtain approval after the test has been performed, but it would require your MD talking with and providing evidence of necessity to your insurance company.  Insurance companies do not decide by themselves what is medically necessary, they are following established medical procedure consensus. 
 

Zaos said:   The point is price disclosure up front vs. an opaque mess.

A lot of this could be avoided by cranking up the deductibles and HSA limits. On average, the cheaper premiums should more than cover any costs like these.

There is nothing that is opaque.  If he had called the lab in advance for the price of the test they would have told him.  OP wrongly assumed:

* test was necessary,
* MD would ask for approval,
* MD would send blood to an in network provider,
* the insurance company would cover the test.

OP made too many assumptions.

Time for single payer, that is the only reasonable solution to the crazy, purposefully opaque and greedy system.

Thanks for all the comments. The fact that he is getting a prior approval - doesn't that imply that he is going to go ahead when the approval is obtained.

That would certainly be my argument. He said he was getting prior authorization. If he was unable to do so, he should have gotten authorization from you before proceeding.

sunrise said:   Thanks for all the comments. The fact that he is getting a prior approval - doesn't that imply that he is going to go ahead when the approval is obtained.
The way it normally works is that the lab will not perform the procedure until they have received approval from your insurance company.  The lab does not want to get stuck with a $3,000 bill because the patient can not pay.  It makes no difference to your MD whether or not the lab gets paid.  The MD can not be an expert on what kind and under what conditions each insurance company might want pre-approval. 

sunrise said:   .
 

sunrise,

If the test was done in June, and you have already received a letter from your insurance company saying that they will not pay the bill, then you may have been getting bills at home from the lab that ran the test, and those labs generally don't wait for many months of non-payment before they send the debt to a collection agency, so you will want to get this sorted out quickly in order to protect your credit rating.

Did you contact the doctor's office and find out what action he took when he said that he would get prior authorization for the test - did he get authorization - if he didn't, why didn't he get in touch with you and get your permission to do the test, etc.?

Since knowing about the patient's genetic status is not necessary for a diagnosis of frontotemporal dementia, and generally that genetic test is done after the patient meets with a genetic counselor, why did the neurologist do the genetic test on you without sending you to a genetic counselor -- was it a common medical procedure that he followed, or is there any way that you can claim that the testing was unorthodox and therefore you shouldn't have to pay for that, if you did not agree that he could go outside the rules of Blue Cross Anthem? 

Do you think that perhaps at the appointment you agreed that he could do this test even if insurance didn't pay for it, but you didn't understand at the time quite what you were agreeing to?

Have you contacted the lab that is billing you and explained what the situation is, and asked them if they could give you a discount -- or, if they won't discount it, if they could give you extra time to pay?

If you file an appeal with the insurance company, you can ask the lab which is sending you the bill to give you extra time to await the outcome of the appeal - they will often give you another couple of months before sending your bill to a collection agency, but you have to make sure that it is a firm offer from their side (you should write down the names of those you talk to on the phone, the dates of the phone calls, the contents of every phone call).
 
Insurance is very tricky these days and the patient has to do so much self-protection and bureaucratic legwork.  Other posts above have described all the extra steps that patients need to take in order to make sure they and their doctors are following the rules of their insurance company to the letter.

If you do have a diagnosis of dementia, you might want to see if there is someone you trust, like a reliable and kind family member, who can give you a bit of assistance in planning out and arranging for your medical care, just keeping an eye on situations like this, where what a high-powered specialist like the neurologist breezily half-explains in 15 seconds while not even making eye contact with you can later cost you an unexpected several thousand dollars. 

(I have some relatives whom I help like that, and there have been more than a dozen situations in the last 2 years where just having me as an extra observer, who has flagged things up and who has looked into paperwork and billing discrepancies, not to mention actual treatment contradictions and mistakes on the part of the medical people, the hospitals & rehab centers, and the insurance companies, has made a real difference for my relatives.)

If you felt comfortable with it, you could take a friend or relative into some of your medical appointments with you, so they can listen and take notes to make sure that you get the most medical information possible out of the consultation.  (If you did not want anyone with you in an appointment, you could always ask the medical professional if they would mind if you recorded the appointment via the recording function of your cell phone, so that you could play it back later when you were at home, so you wouldn't have to try to remember everything that was said and instructed by the doctor.)

Something tells me that either that doctor has a stake in that lab through his wife or a nephew, or even a stranger who sends him a quarterly royalty check.
 

HumDoHamaraDo said:   Time for single payer, that is the only reasonable solution to the crazy, purposefully opaque and greedy system.

In this case the only difference would be the doctor wouldn't have ordered the test in the first place.

Rubl said:   Something tells me that either that doctor has a stake in that lab through his wife or a nephew, or even a stranger who sends him a quarterly royalty check.
  

That crossed my rather cynical mind when I first read this thread.  The whole situation sounds a bit bizarre to me.

OP:  What was the MD's rationale for having the test in the first place?


 



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