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I had a physical at a new doctor because my union has an annual physical agreement with a medical office that is a participating provider of my employer's health insurance, and the union picks up any co-payments associated with the more comprehensive exam than is required to be covered in full by law.  Based on one of the tests, I received a call from his office, from a doctor who told me she is calling from his office, and he wants me to come in for an specifically stated type of additional test that his office conducts on Friday.  I stated that I have to check with my insurance first to make sure it is covered and I do not need preauthorization, and was informed that they checked, and it is covered.  I said 'okay', scheduled a time for the test, then called my insurance, and was informed that the type of test I was told I was coming in for was covered if given by a participating provider, which this office was.  About a month after being given the test, I received a statement from my insurance listing the test as given by a different, non participating provider.  Besides showing I owed an amount they determined for the stated test that the insurance company would have paid if it was given by a participating provider, t also had 2 other tests listed, which were both unauthorized and given by a non participating provider, meaning I am responsible for the full amount billed. I was informed that if a participating provider performed unauthorized tests, I have no financial responsibility for them. I was never informed that anything performed would be separate and not part of the stated test, and when the tests were performed, was not informed that parts of what were being done were not all part of the stated test. I had no experience with this type of test to lead me to question that I was having separate and distinct tests performed.

The insurance company has now determined that the tests I was not informed about were unnecessary and medically unproven, meaning that the 'out of network' deductable does not apply, and I am responsible for thousands both for the insurance determined amount for the stated test plus the full amount billed for the unauthorized tests.  If given by a participating provider, I would have been responsible for a $20 in network copay for the stated test, and nothing for any unauthorized tests.   If I was told an outside provider would have been performing anything, I could have requested a prescription and gone to multiple participating providers.. If the prescription listed multiple tests, I would have asked the doctor's office about it, called my insurer, and, apparently, been informed that the additional tests were not covered, and not consented to them  I never consented or signed any authorization with the outside provider, and on the form I signed with the medical office where my physical exam  was performed stating that I would be responsible for any uncovered charges, I crossed out where I would be responsible, and inserted my union's name.

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Is this lab work? It is pretty common for these to be sent outside to an external company. You always need to ask the question (their lab or someone else's) or end up with unexpected bills.

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tennis8363 said:   Is this lab work? It is pretty common for these to be sent outside to an external company. You always need to ask the question (their lab or someone else's) or end up with unexpected bills.
No.  No lab work or interpretation of a test given by the participating provider.  No one that worked for the participating provider's office did anything related to giving this test except arrange it. Nothing was sent anywhere by the participating provider's office, as they did nothing. 

I was told that they were giving the test in their office, without their stating that the person that gave me the test in their office didn't work for their office, but worked for a different, non participating provider.

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It's likely you have been legally scammed.  You'll want to do all further communication by certified mail and you want to contact your state's insurance department and possibly your representative.  You might want to dig further into the doctor's business relationship with the testing company.

Doctors are frequently silent partners in various blood and imaging test providers.  They send you "down the hallway" to another entity that they know only bills out of network. 

In this case for example, they charged, and defended a $30,000 charge for a CAT scan that is typically $500:  https://www.youtube.com/watch?v=Qyc6pBYx7Cw




The problem is that somewhere you signed a form agreeing to pay, literally, whatever they decided to charge.  It's the "free market" after all.

 

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ultrancw said:   It's likely you have been legally scammed.  You'll want to do all further communication by certified mail and you want to contact your state's insurance department and possibly your representative.  You might want to dig further into the doctor's business relationship with the testing company.

Doctors are frequently silent partners in various blood and imaging test providers.  They send you "down the hallway" to another entity that they know only bills out of network. 

In this case for example, they charged, and defended a $30,000 charge for a CAT scan that is typically $500:  

The problem is that somewhere you signed a form agreeing to pay, literally, whatever they decided to charge.  It's the "free market" after all.

 

Thank you.  A 'relationship' between the doctor and the outside provider is interesting.

And, no.  I didn't sign anything with anyone anywhere agreeing to pay anything.  I was neither provided with nor signed anything with the undisclosed outside provider that performed the test  And, with the participating provider who arranged the test conducted in his office  as my union has an agreement with them to cover all co-pays associated with the physical exam I saw him for, I crossed off the words on the form where "I" agreed to pay any fees or charges not covered by insurance and wrote in my union's name before signing the form, although that may be irrelevant as they didn't perform the test or bill my insurance for the test..

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They should apply usury-type laws to healthcare as well. So many easy ways to help fix the high cost of healthcare:

- Allow importing of prescription drugs from Canada/other countries OR set price caps equivalent to what those in other 1st world countries pay.
- Set limits on malpractice lawsuits for intangible/punitive damages (thereby reducing the high cost of malpractice insurance which gets passed onto the customer).
- Price caps on medical services not to exceed local average by X%.
- Requiring medical providers to post a rate sheet online, so consumers can comparison shop BEFORE getting services.

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All I've got to say is that this sucks.

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Get your union involved, let them know what happened and see if they can assist.

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ArmchairArchitect said:   They should apply usury-type laws to healthcare as well. So many easy ways to help fix the high cost of healthcare:

- Allow importing of prescription drugs from Canada/other countries OR set price caps equivalent to what those in other 1st world countries pay.
- Set limits on malpractice lawsuits for intangible/punitive damages (thereby reducing the high cost of malpractice insurance which gets passed onto the customer).
- Price caps on medical services not to exceed local average by X%.
- Requiring medical providers to post a rate sheet online, so consumers can comparison shop BEFORE getting services.

Require disclosure of all rate sheets by insurers and providers. Legally set disputed amounts at the lowest rate, similar to most favored nations clauses.

Malpractice is complicated. Some bad apple doctors should be shut down. Then reassess how the others are being impacted. Some docs pull really shady stuff so why should damages be limited. It's already hard enough to find a lawyer and win a case.    

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I would dispute the charge with the test provider. If they don't agree, let it go to collections, and then ask them to prove that you actually owe the money. They need your signature somewhere.

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bobley said:   
ArmchairArchitect said:   They should apply usury-type laws to healthcare as well. So many easy ways to help fix the high cost of healthcare:

- Allow importing of prescription drugs from Canada/other countries OR set price caps equivalent to what those in other 1st world countries pay.
- Set limits on malpractice lawsuits for intangible/punitive damages (thereby reducing the high cost of malpractice insurance which gets passed onto the customer).
- Price caps on medical services not to exceed local average by X%.
- Requiring medical providers to post a rate sheet online, so consumers can comparison shop BEFORE getting services.

Require disclosure of all rate sheets by insurers and providers. Legally set disputed amounts at the lowest rate, similar to most favored nations clauses.

Malpractice is complicated. Some bad apple doctors should be shut down. Then reassess how the others are being impacted. Some docs pull really shady stuff so why should damages be limited. It's already hard enough to find a lawyer and win a case.    

Perhaps it depends on where you live, but, from what I've seen, some lawyers will take anything that walks in the door, file an action for anything, a 'nuisance case', knowing that it's cheaper for the defendant, often an insurance company, whether for malpractice insurance, auto insurance or something else (this goes for all types of actions, not just medical malpractice) to settle than defend against it, incurring legal fees for pre-trial and trial proceedings and witnesses, including doctors who might get $5000 or more to show up for a few hours.  Basically, it's a type of extortion, settle or pay $50,000. or whatever to defend against it, even if it's bull. And, of whatever they settle or win, the lawyer gets a third.  Also, some lawyers have certain specific doctors that they refer their clients to, who always find something that works perfectly with the plaintiff's case, and then get that big fee to testify about it.  It's not just plaintiff's attorneys, as for each action filed, the defendant has to hire defense counsel, all of whom either receive  hundreds an hour (maybe $250-$400, and more for some specialized attorneys), unless they're on a retainer or on staff, in which case, they receive an attorney's salary, so they win also.  The longer they stretch the proceedings out, the more hours they get paid for.

That said, if the plaintiff doesn't want to settle for what the defendant offers, or it's a real and serious case and they can't meet on a settlement, they'll actually have to prove something to the satisfaction of a jury.which will require an attorney with the knowledge and ability to conduct a malpractice trial.  There are "trial counsel" that other lawyers hire for that purpose.

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ultrancw said:   It's likely you have been legally scammed.  You'll want to do all further communication by certified mail and you want to contact your state's insurance department and possibly your representative.  You might want to dig further into the doctor's business relationship with the testing company." 

 

  Maybe also dig into your union's relationship with that doctor...

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Without knowing the tests done, really hard to figure out what's going on.

I doubt it's legit to cross out where you are supposed to sign and sign some other person or entity.

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dhodson said:   Without knowing the tests done, really hard to figure out what's going on.

I doubt it's legit to cross out where you are supposed to sign and sign some other person or entity.

Test I was told would be performed:  Nerve conduction test
Additional tests performed without my being informed that they were separate tests and not part of the nerve conduction test:  Ultrasound tests.

Having now looked them up, I see where there were separate tests.  At the time, they were performed, all with handheld devices, with my not moving from the same spot for all the tests, and without my being informed that they were not part of the same test, so I could look them up. I was unaware

And, for whatever reason or irrelevance you're stating that it's not legit to sign another person or entity's name on the signature line of a document,  I agree that forging some one or some other's name is not legit. I suggest that you don't do it, as I certainly wouldn't.

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Well bc when you did that, it is assumed you had authority to do that and make the union responsible which you didn't and thus likely made you liable for the charges.

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dhodson said:   Well bc when you did that, it is assumed you had authority to do that and make the union responsible which you didn't and thus likely made you liable for the charges.
Because I did what?
I didn't make the union responsible for anything.  The union made themselves responsible for any charges incurred from the physical by making an agreement with the medical office to be directly billed for, and to pay all copays and charges (as they are a participating provider, all physical related costs should be limited to copays), incurred during the annual physical and providing this as a "benefit" to members.  As the agreement between the union and the medical office is for the union to be billed for the physical copays and charges, I see no reason why the office would give me the standard form that states that I would be responsible.  As such I crossed off the "I" and replaced it with the name of my union, the party that assumed responsibility for me, before I signed it.  That I did not agree to pay that providers copays for the physical, which my union had a agreement with the doctor to cover, and which was a benefit provided to me as of record, does not make me responsible for charges some other provider I never heard of, had no agreement with, and signed nothing with decided to bill for a test I never consented or was informed would be performed by anyone other than the participating provider, nor for other tests I never was informed about at all, and never consented to have performed by anybody. And, for whatever you contend that I did that you state made me liable for the charges, I contend that by posting your comment regarding me making myself responsible for something, that you made yourself responsible for the charges.

I have a bank account that (at least used to) provide free McAfee internet security.  If I signed up for the free security through the link or code where my bank and McAfee had an agreement that there would be no cost to me, do you feel that by doing that, I would be assuming financial responsibility if Norton installed itself on my computer and then billed me?

 If the participating provider actually performed the test themselves, as they indicated, and the tests were covered by my insurance, as the participating provider explicitly told me (and the insurance company confirmed would be if given by a participating provider, when I called them before getting the test), I would have been responsible for $20 per test.  As the 3 of the tests I was never informed were separate from the test I consented to, were not approved by my insurance, my insurance company representative told me I would had not been responsible for anything if the participating provider had taken it upon themselves to performed them..

 

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the real question here ... is why cant u break up your posts like this.
Every once in a while just do this 
...
makes it easier to read

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I work in a doctor's office and we bill insurance as a courtesy. It doesn't matter what the insurance company tells us, the patient is ultimately responsible for the bill. We get authorization all the time with a disclaimer from the insurance company stating the authorization does not guarantee payment. Patient is responsible for payment. We contact the insurance company and write down agent's name, date/time when they tell us the procedure is covered. Then when the bill is is denied because it is not covered by the insurance we have something to show the patient. Fight the bill with your insurance company. Doctor's office and patients are told procedures are covered when they aren't by the insurance company. Don't blame the doctor, blame the insurance company or your union office. More of us are shelling more and more out of our pocket including my boss - healthcare is still broken in this country unfortunately. Hopefully the tests were useful in diagnosing your health problem or preventing future ones.

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abcguy28 said:   I work in a doctor's office and we bill insurance as a courtesy. It doesn't matter what the insurance company tells us, the patient is ultimately responsible for the bill. We get authorization all the time with a disclaimer from the insurance company stating the authorization does not guarantee payment. Patient is responsible for payment. We contact the insurance company and write down agent's name, date/time when they tell us the procedure is covered. Then when the bill is is denied because it is not covered by the insurance we have something to show the patient. Fight the bill with your insurance company. Doctor's office and patients are told procedures are covered when they aren't by the insurance company. Don't blame the doctor, blame the insurance company or your union office. More of us are shelling more and more out of our pocket including my boss - healthcare is still broken in this country unfortunately. Hopefully the tests were useful in diagnosing your health problem or preventing future ones.
  Thank you for your experienced information.  I will call the insurance company tomorrow and see if they have any record of anything specifically relating to my account.  From my prior conversations with the insurance company, no authorization is needed for the nerve conduction test as it is covered if given by a participating provider, if it's given by a non participating provider, it is not covered as there are participating providers available.  They mentioned nothing about any authorization for the other tests which I was not informed about and did not consent by any manner to have done  And, besides that they were denied as mot medically demonstrated, and even if it was a routinely given and covered test, it  would not have been approved for a non participating provider when participating providers are available. If the participating provider gave me the tests, as they indicated, I would have owed a $20 copay for the covered test, and no copays for anything else a participating provider decides to do without authorization form my insurance.  My insurance, ultimately United Healthcare, informed me that the agreement they have with participating providers provides for this.  A participating provider can't do whatever they want then bill the patient whatever they want.  This is part of "participating".  Regarding them representing that they, a participating provider, will do something, then secretly bringing in a non participating provider without me being notified in any manner that the test giver is not actually employed by the participating provider, but by a different entity that does not accept my insurance, and will bill as such, it seems like fraud to me.  Does your office have employees that show up at other doctor's offices, and administer tests to people who have insurance you don't accept, while keeping this fact secret from them, while the office the test is administered in misrepresents that they are administering the test, and then you bill out of network for these tests?


I most certainly blame the doctor's office for calling me, and telling me they wanted me to get an additional test they are giving in their office and is covered by my insurance when, in fact, they were not conducting it, a fact I never found out until receiving documents from my insurance provider.  It was being conducted by a traveling test giver who shows up in the participating provider's office without anyone ever telling me he is separate from the office, doesn't participate in my insurance, and for whom my insurance would never approve anything when there are participating providers available, And, I absolutely blame them for telling me they are going to give me a specific type of test, and they proceed to have multiple tests given, which, since I never had that test before, I had no way of knowing were not part of the stated test, and would not have had performed if informed about them, as I would have called my insurance and been told they were not covered.  I could just have easily gone to a participating provider and owed $20 total, as, if a participating provider takes it upon themselves to give an unapproved test without prior authorization, my insurance told me I don't owe anything, because participating providers agreed to this when becoming "participating".

And, I don't know about this test diagnosing or preventing anything, because, in the 4 1/2 months since I had the tests, no one has contacted me with any results or told me to make an appointment to review them.. And, while I wasn't told what they were really looking for, looking it up, I believe the additional tests I was never informed about, but were billed and are not covered, relate to chronic autoimmune conditions for which I have been seeing a specialist for years, and have already had an MRI and x-ray which show the area I believe they were looking at.

To me, this seems similar to my going to a restaurant where the salad bar is included in my $15.99 meal.  Then, getting 2 bills, one for $15.99, and one for $3000, because the restaurant decided to let an outside entity set up part of the salad bar inside the restaurant one day, with no notice to customers that it wasn't part of the restaurant, invited customers to enjoy the included salad bar and then the outside entity charged whatever they wanted to anyone that took something from their undesignated section of the salad bar.

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Sounds like unless you can convince your insurance company you don't owe the money, you're on the hook for those charges.

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I'd start by contacting the physician who ordered the test. Let them know, politely and simply, what happened and ask them to have the provider remove the incorrect test. The doctor is going to have more knowledge about what is going on and more clout than you will, pretty good chance the doctor will get it taken care of.

ETA: Have you determined whether your physician ordered the tests or whether they were done without any sort of medical order?

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zimmie:
What good does it do the OP if his insurance company decides he/she doesn't owe an unrelated party money?
His insurance company has already determined the insurance company doesn't owe anything.

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This is why I never have any of the tests that my Doctor wants me too. Too hard to figure out if it will or won't be covered. Repeal this mess, none of us have insurance!

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OP, sorry for not reading the entire wall of text, but I do have a suggestion on where else to start.

The simple thing you can do that can help chip away at what was billed is to get the full itemized statement of every CPT code (procedure code) and the corresponding ICD codes (diagnostic code). These are required to bill insurance, so don't let them tell you they don't have them.

The medical provider is required to provide you this information in writing upon request, but unfortunately the insurance provider is not (although you can get the insurance CSR to read them to you verbally over the phone).

Go through each procedure code and make sure you actually received the procedure/test (note you are entitled to a printout of every test result/analysis/report).  Watch out for procedure codes that indicate a higher level of complexity/complication than applied to you.

Then go through every diagnostic code and make sure it's valid. Not just valid as in billable, but as in the truth. Some diagnostic codes will correspond to patient complaints/requests. If you didn't say anything to warrant the ICD code the test was unnecessary and you can fight that much easier.

If the insurance is saying that a test was medically unnecessary, so I'm guessing that the ICD codes are either unbillable or aren't meaningful enough to warrant the procedure code. Use that as the basis to file a formal complaint against the medical provider. If they ordered/performed enough unnecessary tests, just doing your homework and preparing the complaint may be enough to get the provider to drop all billed charges.

Use Google/Wikipedia to look up the meaning of the CPT and ICD codes.

Good Luck

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cows123 said:   
abcguy28 said:   I work in a doctor's office and we bill insurance as a courtesy. It doesn't matter what the insurance company tells us, the patient is ultimately responsible for the bill. We get authorization all the time with a disclaimer from the insurance company stating the authorization does not guarantee payment. Patient is responsible for payment. We contact the insurance company and write down agent's name, date/time when they tell us the procedure is covered. Then when the bill is is denied because it is not covered by the insurance we have something to show the patient. Fight the bill with your insurance company. Doctor's office and patients are told procedures are covered when they aren't by the insurance company. Don't blame the doctor, blame the insurance company or your union office. More of us are shelling more and more out of our pocket including my boss - healthcare is still broken in this country unfortunately. Hopefully the tests were useful in diagnosing your health problem or preventing future ones.
  Thank you for your experienced information.  I will call the insurance company tomorrow and see if they have any record of anything specifically relating to my account.  From my prior conversations with the insurance company, no authorization is needed for the nerve conduction test as it is covered if given by a participating provider, if it's given by a non participating provider, it is not covered as there are participating providers available.  They mentioned nothing about any authorization for the other tests which I was not informed about and did not consent by any manner to have done  And, besides that they were denied as medically demonstrated, even if it was a routinely given and covered test, it  would not have been approved for a non participating provider when participating providers are available.  


I most certainly blame the doctor's office for calling me, and telling me they wanted me to get an additional test they are giving in their office and is covered by my insurance when, in fact, they were not conducting it, a fact I never found out until receiving documents from my insurance provider, and it was being conducted by a traveling test giver who shows up in the participating provider's office without anyone ever telling me he is separate from the office, doesn't participate in my insurance, and for whom my insurance would never approve anything when there are participating providers available, And, I absolutely blame them for telling me they are going to give me a specific type of test, and they proceed to have multiple tests given, which, since I never had that test before, I had no way of knowing were not part of the stated test, and would not have had performed if informed about them, as I would have called my insurance and been told they were not covered.  I could just have easily gone to a participating provider and owed $20 total, as, if a participating provider takes it upon themselves to give an unapproved test without prior authorization, my insurance told me I don't owe anything.

And, I don't know about this test diagnosing or preventing anything, because, in the 4 1/2 months since I had the tests, no one has contacted me with any results or told me to make an appointment to review them.. And, while I wasn't told what they were really looking for, looking it up, I believe the additional tests I was never informed about, but was billed amd are not covered, relate to chronic autoimmune conditions for which I have been seeing a specialist for years, and have already had an MRI and x-ray which show the area I believe they were looking at.

To me, this seems similar to my going to a restaurant where the salad bar is included in my $15.99 meal, and getting 2 bills, one for $15.99, and one for $3000, because the restaurant decided to let an outside entity set up part of the salad bar inside the restaurant one day, with no notice to customers that it wasn't part of the restaurant, invited customers to enjoy the included salad bar and then the outside entity charged whatever they wanted to anyone that took something from their undesignated section of the salad bar.
 

  

Somehow, sure sounds like the doc is getting a kickback from these road-show lab folks and maybe is ordering unnecessary tests to pad those kickbacks.  Wouldn't be the 1st time that has happened. 

 

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abcguy28 said:   I work in a doctor's office and we bill insurance as a courtesy. It doesn't matter what the insurance company tells us, the patient is ultimately responsible for the bill. We get authorization all the time with a disclaimer from the insurance company stating the authorization does not guarantee payment. Patient is responsible for payment. We contact the insurance company and write down agent's name, date/time when they tell us the procedure is covered. Then when the bill is is denied because it is not covered by the insurance we have something to show the patient. Fight the bill with your insurance company. Doctor's office and patients are told procedures are covered when they aren't by the insurance company. Don't blame the doctor, blame the insurance company or your union office. More of us are shelling more and more out of our pocket including my boss - healthcare is still broken in this country unfortunately. Hopefully the tests were useful in diagnosing your health problem or preventing future ones.
  
This is useful input.   Many billing problems indeed aren't the doctor (or his/her employees) screwing people over, but some definitely are.  The worse situations are when one is in an emergency or urgent situation of course.  If it's routine, one should be able to confirm the authorization with the insurance company, ideally by email. Or use a smart phone to record the call. 

I once went to a doctor and he insisted I need a CAT scan and gave me already filled out form for a scanning place, saying that I should go there. When I told him I'd check with my insurance for an in network place I could see him get slightly peeved at me.  I knew I was being set up. The place he recommended I get the scan cost $900 and didn't accept *any* insurance plans.  The place I went to that I found on my own was $280 with my insurance's in-network negotiated rate.  Ironically it was literally a 5 minute walk away from his office while the other place was a 20 minute drive. 

One needs to be defensive like this is and also about blood tests. Labcorp and Quest do most of the blood testing in the country but some doctor practices create XYZ LLC that supposedly does the blood test, which is simply sent to Labcorp or Quest.  XYZ LLC charges $500 for a CBC type test that would normally be under $50.  For most blood testing if you're paying for it out of pocket, it's often better to just get it done via discount blood testing websites like Walkinlab or Mydirectlabs (which themselves contract with the two bigs), unless you have rock solid confirmation you will be charged a similar fair market rate. 

 

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as info for consumers:

walkinlab uses labcorp
myDirectlabs uses quest

Not sure that you can live anywhere in the CONUS and not have one of those two serving your area.

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abcguy28 said:   I work in a doctor's office and we bill insurance as a courtesy. It doesn't matter what the insurance company tells us, the patient is ultimately responsible for the bill. We get authorization all the time with a disclaimer from the insurance company stating the authorization does not guarantee payment. Patient is responsible for payment. We contact the insurance company and write down agent's name, date/time when they tell us the procedure is covered. Then when the bill is is denied because it is not covered by the insurance we have something to show the patient. Fight the bill with your insurance company. Doctor's office and patients are told procedures are covered when they aren't by the insurance company. Don't blame the doctor, blame the insurance company or your union office. More of us are shelling more and more out of our pocket including my boss - healthcare is still broken in this country unfortunately. Hopefully the tests were useful in diagnosing your health problem or preventing future ones.
  So typically DRs offices have something in writing from insurance stating it's covered?
Does the office provide that documentation to patients upon request?

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abcguy28 said:   I work in a doctor's office and we bill insurance as a courtesy. It doesn't matter what the insurance company tells us, the patient is ultimately responsible for the bill. We get authorization all the time with a disclaimer from the insurance company stating the authorization does not guarantee payment. Patient is responsible for payment. We contact the insurance company and write down agent's name, date/time when they tell us the procedure is covered. Then when the bill is is denied because it is not covered by the insurance we have something to show the patient. Fight the bill with your insurance company. Doctor's office and patients are told procedures are covered when they aren't by the insurance company. Don't blame the doctor, blame the insurance company or your union office. More of us are shelling more and more out of our pocket including my boss - healthcare is still broken in this country unfortunately. Hopefully the tests were useful in diagnosing your health problem or preventing future ones.
 

 
The problem here is that we have a pretty clear case of the doctor deliberately and silently going out of network in order to get money for something that shouldn't have been done in the first place.  This isn't a matter of the courtesy of billing insurance, this is a scam.

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Question for folks here... What exactly is the point of getting CPT codes and such...since that has no bearing on what they will charge for said services. Yes, you may be able to find a service you didn't get, but what if we're just talking about outrageous prices of a service?

At the end of the day, anytime something is deemed "out of network" they could charge you $200 or $200,000.... How do they draw the line on what an ethical acceptable amount is and what is not?

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ultrancw said:   
abcguy28 said:   I work in a doctor's office and we bill insurance as a courtesy. It doesn't matter what the insurance company tells us, the patient is ultimately responsible for the bill. We get authorization all the time with a disclaimer from the insurance company stating the authorization does not guarantee payment. Patient is responsible for payment. We contact the insurance company and write down agent's name, date/time when they tell us the procedure is covered. Then when the bill is is denied because it is not covered by the insurance we have something to show the patient. Fight the bill with your insurance company. Doctor's office and patients are told procedures are covered when they aren't by the insurance company. Don't blame the doctor, blame the insurance company or your union office. More of us are shelling more and more out of our pocket including my boss - healthcare is still broken in this country unfortunately. Hopefully the tests were useful in diagnosing your health problem or preventing future ones.
  
This is useful input.   Many billing problems indeed aren't the doctor (or his/her employees) screwing people over, but some definitely are.  The worse situations are when one is in an emergency or urgent situation of course.  If it's routine, one should be able to confirm the authorization with the insurance company, ideally by email. Or use a smart phone to record the call. 

I once went to a doctor and he insisted I need a CAT scan and gave me already filled out form for a scanning place, saying that I should go there. When I told him I'd check with my insurance for an in network place I could see him get slightly peeved at me.  I knew I was being set up. The place he recommended I get the scan cost $900 and didn't accept *any* insurance plans.  The place I went to that I found on my own was $280 with my insurance's in-network negotiated rate.  Ironically it was literally a 5 minute walk away from his office while the other place was a 20 minute drive. 

One needs to be defensive like this is and also about blood tests. Labcorp and Quest do most of the blood testing in the country but some doctor practices create XYZ LLC that supposedly does the blood test, which is simply sent to Labcorp or Quest.  XYZ LLC charges $500 for a CBC type test that would normally be under $50.  For most blood testing if you're paying for it out of pocket, it's often better to just get it done via discount blood testing websites like Walkinlab or Mydirectlabs (which themselves contract with the two bigs), unless you have rock solid confirmation you will be charged a similar fair market rate. 

 

Sometimes doctors are required by contract to refer patients only to facilities/physicians within their own hospital/group. Not saying that's what happened in your case, but it's something to be aware of.

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justignoredem said:   Question for folks here... What exactly is the point of getting CPT codes and such...since that has no bearing on what they will charge for said services. Yes, you may be able to find a service you didn't get, but what if we're just talking about outrageous prices of a service?

At the end of the day, anytime something is deemed "out of network" they could charge you $200 or $200,000.... How do they draw the line on what an ethical acceptable amount is and what is not?

  
It helps you to determine what services exactly you are being billed for and what a reasonable amount for those services would be. How would you know if the bill is outrageous if you have no basis for comparison?

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justignoredem said:   Question for folks here... What exactly is the point of getting CPT codes and such...since that has no bearing on what they will charge for said services. Yes, you may be able to find a service you didn't get, but what if we're just talking about outrageous prices of a service?

At the end of the day, anytime something is deemed "out of network" they could charge you $200 or $200,000.... How do they draw the line on what an ethical acceptable amount is and what is not?

  
A couple of things here.  Finding services and diagnostic codes that are inappropriate is a much easier argument than they charged too much.

1. Are you being billed for something you actually received?  For example, in a routine office visit, the doctor could bill with CPT codes 99211, 99212, 99213, 99214, or 99215 (not limited to list).  You will find a 'similar' description for each one, but 99215 may legitimately pay 10x more than 99211.  The key is that the patient needs to present conditions/symptoms that warrant using a higher complexity code.  Other times it is more black and white such as a hospital checking off all the usual CPT's for a birth without checking if they were provided.  I've known people to find circumcision on the superbill for an uncircumcised baby.

2. This one is sneakier, but can be easier to figure out.  Did all the diagnostic codes correspond to a condition/complaint/symptom/...  Medicare is still trying to crackdown on doctors using ICD's that correspond to a verbal complaint to order expensive tests.  Some doctors are so slick, the figure out how to elicit a comment out of the patient.  Others are so blatant, they just order the test without telling the patient why and put down that the patient complained. 

Doctors can make mistakes and generally, patient's are on the hook for the bill for services received.  Doctors that make up reasons to order tests are not making a mistake, they are committing fraud.  Most would agree that the patient should not be liable for fraudulently ordered tests.  With healthcare costs in the spotlight, the bigger the fraud, the easier it is to get your complaint attention. Any over billed services are leverage to getting the bill reduced to a normal rate.

In-Network and Out-of-Network are determined by who performed the service, not what they performed.  It's hard to get through to the right department, but Insurance Providers will generally help you out and go to bat for medical fraud with In-Network Providers.  No In-Network provider should be billing you for a covered benefit that your insurance denied.  The EOB should spell out the denial reason.

With Out-Of-Network providers, call it what it is "Medical Fraud" and complain to everyone.  The certification board, state attorney general, news outlets, BBB, Federal Trade Commission, State Dept. of Professional Regulation.

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Your insurance company should have an appeal and grievance procedure. You should start there and also file complaints with every state agency, Insurance regulators and your state medical board.

I know for my insurance and plan contract that any service given during the same visit is only billed as a regular dr visit. So if the Dr orders an EKG or Ultrasound they have to schedule it separately on another day or at another location or the insurance company denies it ( and by contract cannot come after the patient for the deficiency ) unless it is coded JUST right. Labs also have to be done separately or negotiated and sent out to an approved lab, or the aren't covered and you don't have to pay for them either.

You should ask for a fully itemized bill including ICD codes and provider codes.

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