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Hi folks,

My wife and I are expecting our third child in the Spring. Given my wife's age (over 35), her OB suggested that she do genetic testing to screen for Down syndrome as well as a host of other genetic disorders. "It's a simple blood test now," her OB said, "usually covered 100% by insurance." We agreed. First, though, I contacted my insurer (Aetna) and asked about coverage for pre-natal genetic testing. I received written confirmation that genetic testing is covered by our plan, but our deductible will apply. Fine.

So, the wife has the blood draw. Two weeks have now gone by and we have not heard any results from the test. What I have seen, however, is the EOB from Aetna. The genetic testing company billed my insurer for $8,000. My insurer paid nothing, $750 will apply to our deductible, and we're on the hook for an additional $5,000 that Aetna doesn't cover.

The big problem is one of the individual tests that the company performed. They screened for genetic microdeletions, which I had never heard of until today, and they billed Aetna $5,000 for this screening. The Aetna EOB just says "not covered" for this test, and they're passing the cost along to me. If I had known then what I know now, there's no way we would have done genetic testing, especially since these tests have a low accuracy rate with an unusually high number of false positives. At present, though, we're looking at a $5,750 blood draw. Ouch.

We have not yet received a bill. I'm waiting to see how the genetic testing company proceeds. There's no way I will pay this much for the testing. At best, I will agree to a significantly reduced amount, maybe 10%. Otherwise, I'll let them send it to collections and pay pennies on the dollar.

I post this story partly as a warning to others, and partly to ask if anyone has any advice or has dealt with a similar situation. Do you think it wise for me to contact the genetic testing company before we receive a bill to see what they have to say?

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I've dealt with this and my understanding has been ACA does fix this pretty well if dealt with properly. If your doctor... (more)

fourchar (Sep. 16, 2017 @ 2:31p) |

I wouldn't worry about this.
Offer them $200 and it will go away.

Unfortunate way the system works.

We have to bill everyon... (more)

JacksonX (Sep. 17, 2017 @ 6:49a) |

You mean erudite wisdom and razor sharp wit, not "stuff".

I've read far too many depressing stories of people who have ba... (more)

ganda (Sep. 18, 2017 @ 8:53a) |

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Any connection between the doctor and the lab? This doesn't sound right.

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No idea. I wouldn't be surprised if they had some kind of "kickback" system, but I don't know how I would ever find out that information (or if it would even help). I'm not even sure who I should approach about this problem: the OB, my insurer, or the genetic testing company? Or maybe I should just wait and see what happens?

Maybe the genetic testing company will eat the cost of it and bill me a small amount, as if I didn't have insurance. One can dream, right?

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What company was the genetic testing through? We had a similar situation, but the company laid out billing before running the test after getting our insurance info - either out of pocket ($299) or through insurance ($750+). We chose through insurance knowing we would meet our deductible anyway.

I think the company was Counsyl

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The company is called Natera. I wasn't present when my wife signed any paperwork, so I don't know if she had a similar option.

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This underscores the importance of preauthorization.

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stanolshefski said:   This underscores the importance of preauthorization.
Which he got? Kinda?

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Figure out exactly what the test is for and why it wasn't covered. If you can make a case for why it is important in your wife's particular case, you can appeal to the insurance company, including a letter from the doctor explaining the medical importance.

Failing that, $5,000 is the "rack rate" which should be pretty easy to negotiate down. I'd wait until you get the bill, then make a low-ball offer ($150?), and take it from there.

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Cases like these, which are extremely common, really highlight some of the major issues with the way medical care is billed in this country. None of the proposals from either political party made any attempt to address this type of problem.

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Yes, I got pre-authorization, to the best of the knowledge I had at the time. If I had to do it again, I would ask the provider exactly which tests would be conducted, and I would send that itemized list to Aetna before proceeding with anything.

That's probably good advice for any health-insurance scenario, but what a labyrinthine mess.

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doveroftke said:   Figure out exactly what the test is for and why it wasn't covered. If you can make a case for why it is important in your wife's particular case, you can appeal to the insurance company, including a letter from the doctor explaining the medical importance.

Failing that, $5,000 is the "rack rate" which should be pretty easy to negotiate down. I'd wait until you get the bill, then make a low-ball offer ($150?), and take it from there.

  I appreciate the advice. I will likely wait and see what happens with billing from Natera. It may well be that situations like mine are the norm and that they will automatically reduce the billed amount to a fraction of the original. And there's no way we'll pay $5,000+ for the screening. I'd rather my wife declare bankruptcy first. Natera can pound sand if they want to play hardball.

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habibbijan said:   Yes, I got pre-authorization, to the best of the knowledge I had at the time. If I had to do it again, I would ask the provider exactly which tests would be conducted, and I would send that itemized list to Aetna before proceeding with anything.

That's probably good advice for any health-insurance scenario, but what a labyrinthine mess.

  Pre-authorization is a specific process where the medical provider essentially pre-submits their invoice for approval from the carrier. I doubt that's what happened here.

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In California the state has taken on this testing. The cost is $160 for the blood test and the ultrasound measurements.

https://archive.cdph.ca.gov/programs/gdsp/pages/default.aspx

For some reason my insurance denied the claim (ppo at the time).

I wrote a letter to my insure that the $160 should be covered as preventative prenatal and they paid the claim.

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The labs massively discount. We had roughly the same situation (cost $8k, not covered, EOB from the insurer said we owed $7k). When we got a bill from the testing provider, it showed (round numbers) $8k cost, less $1k paid by insurance, less $6750 courtesy discount, $250 balance.

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cestmoi123 said:   The labs massively discount. We had roughly the same situation (cost $8k, not covered, EOB from the insurer said we owed $7k). When we got a bill from the testing provider, it showed (round numbers) $8k cost, less $1k paid by insurance, less $6750 courtesy discount, $250 balance.
  Agree with this. A lot bill insurance just to get as much as possible then discount it significantly afterwards. Wait until you get the actual bill before you freak out.

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All great to hear, thanks. I'm basically counting on a massive discount from the provider. If they ask for 5k+, they can direct their request for payment to the nearest brick wall.

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habibbijan said:   All great to hear, thanks. I'm basically counting on a massive discount from the provider. If they ask for 5k+, they can direct their request for payment to the nearest brick wall.
  i had to fight the lab in a similar situation. Argued that they should bill me the amount insurance company would pay IF it was covered. 

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doveroftke said:   Cases like these, which are extremely common, really highlight some of the major issues with the way medical care is billed in this country. None of the proposals from either political party made any attempt to address this type of problem.
  Giving everybody a single billing standard is very likely unsustainable.  Right now, some people actually pay the bill in full, and other pay various amounts (different people = different sophistication).  If that revenue were to vanish, nearly everybody's premiums would rise to offset the losses.

(One of my elderly relatives gets "balance billed" a lot.  But she just tells the companies to pound sound, and they do.  Other people aren't putting up as much of a fight, though.  Otherwise, why would these companies even bother to mail invoices?).

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habibbijan said:   All great to hear, thanks. I'm basically counting on a massive discount from the provider. If they ask for 5k+, they can direct their request for payment to the nearest brick wall.
  
Well, don't count on it, but not an unreasonable plan.

I ran into somewhat similar situation. My large bill had to do with how the OB/GYN had coded the request for the test. Was coded as for the mom in general (i.e. genetic screen before getting pregnant) rather than as a diagnostic lab test during a pregnancy (e.g. blood test to screen for Down Syndrome, other trisomies, etc. to prevent need for more invasive testing like amniocentesis). Lab couldn't do much to fix the explanation of benefits due to how was coded, but the OB sent a revised request, copied the insurance company and lab, and it took care of itself (there was a 3-way conference call I believe).

My insurance covers prenatal at 100% without exclusions, so as long as was prenatal and fell within medical guidelines, it was covered. Check you plan brochure.

The big two companies doing these non-invasive prenatal testing (NIPT) are Counsyl and Natera. Both establish relationships (not kickbacks, but referral fee and whatnot) with OBs. They generally are willing to heavily discount if your insurance doesn't cover (or for cash patients).

They also don't get along well. https://www.genomeweb.com/molecular-diagnostics/counsyl-natera-o...

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No advice on how to specifically deal with the bill, but to start...
1. Request a copy of your summary plan description. This is not the 8 page summary they gave you when you signed up, but rather the 100+ page document that details what is covered, what is not, and what sounds like it's covered until it isn't (aka carefully phrased exclusions).
2. Request from the insurance what CPT codes were billed along with the ICD codes. Don't take phrases, get the actual codes.
3. Read up on the real meaning of the codes, especially the diagnostic codes.

Can't really write a choose your own adventure here, but after getting the above info, you are in a better position to know what is covered, what specific tests your doctor ordered, and more importantly "Why" your doctor ordered them. You then cater your approach based on how that info applies to your situation.

The most common exclusion for insurance is a genericized variation on the phrase, not medically necessary. If your doctor has a valid medical reason for ordering the tests, then you can push your doctor into defending the validity of the tests for your situation and formally appealing the insurance to cover it.

Conversely, if the tests ordered had diagnostic codes that didn't apply to your situation, then you start arguing with the doctor and the testing company to discount/waive charges.

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The wife and I have two kids.  We got these tests done but insurance covered the test for both pregnancies.   If we had to pay out of pocket for it, we would have passed on it.  It's a useless test.  

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We just paid a couple thousand for this

I mean, I guess it depends on the person but for us it is definitely not a useless test.  If you are at a higher risk for defects but just don't care if you have a child with defects then yes, useless.  

If you have multiple embryos (IVF) and want to chose the best one...totally worth it.  If you don't want to put yourself through the heartache of terminal complications due to defect.  Totally worth it.

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necac said:   
doveroftke said:   Cases like these, which are extremely common, really highlight some of the major issues with the way medical care is billed in this country. None of the proposals from either political party made any attempt to address this type of problem.
  Giving everybody a single billing standard is very likely unsustainable.  Right now, some people actually pay the bill in full, and other pay various amounts (different people = different sophistication).  If that revenue were to vanish, nearly everybody's premiums would rise to offset the losses.
 

  Do you work for the medical testing industry "New user" (likely alt id)?
How about there be some basis in reality for the amount billed and what is actually paid by folks. I can understand a 10-20% variance between the amounts paid and billed depending on insurance contract. We have folks reporting on this thread that a discount of ~85% was provided on a 8k bill.
How about the company disclose their rate prior to performing the test (as is done in almost any transaction).
 

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RailroadTrack said:   The wife and I have two kids.  We got these tests done but insurance covered the test for both pregnancies.   If we had to pay out of pocket for it, we would have passed on it.  It's a useless test.  It's not completely useless if the mother is over a certain age. I recently read that the risk of certain terrible genetic deceases DOUBLES for women over the age of 35. From like 0.3% to 0.6%, but still... DOUBLES!

Don't quote me on the numbers.

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I went to the ER after i had lasik because i was in so much pain, they had me wait for over an hr and eventually told me i just needed to fill the prescription for the narcotics i got from the lasik doctor
They billed me about $800, i sent a letter to them saying i was not going to pay because they didnt do anything at all, i never got a bill from them again

Most people dont fight, they allow themselves to get taken advantage of, i do not and if need be i have my lawyer send them a letter

 

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Medicine has become a fraud place. You will get a bill for everything. Any procedure done should be writing with amount fee and if it goes over then provider has to write off.

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Take a deep breath, what they bill the insurance and what you may wind up paying is very different. My wife and I had the genetic testing and we received a similar bill, there is often a hardship number to contact that you can call from the company and tell them you simply cant pay it. For us the bill dissapeared and we never heard anything about it again. That was 2+ years ago.

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necac said:   
doveroftke said:   Cases like these, which are extremely common, really highlight some of the major issues with the way medical care is billed in this country. None of the proposals from either political party made any attempt to address this type of problem.
  Giving everybody a single billing standard is very likely unsustainable.  Right now, some people actually pay the bill in full, and other pay various amounts (different people = different sophistication).  If that revenue were to vanish, nearly everybody's premiums would rise to offset the losses.

(One of my elderly relatives gets "balance billed" a lot.  But she just tells the companies to pound sound, and they do.  Other people aren't putting up as much of a fight, though.  Otherwise, why would these companies even bother to mail invoices?).

  
Was this meant as a response to my comment? I didn't ask for a "single billing standard", there's nothing wrong with (at least some types of) price discrimination. There is something wrong with surprise bills and claim denials, particularly when the insurance company said it would be covered.

And balance billing is definitely a problem, illegal in many states and prohibited by every insurance company agreement. It should be illegal in every state with severe penalties for knowing violations.

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The best healthcare system in the world is never going to be cheap.

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whoDean said:   We just paid a couple thousand for this

I mean, I guess it depends on the person but for us it is definitely not a useless test.  If you are at a higher risk for defects but just don't care if you have a child with defects then yes, useless.  

If you have multiple embryos (IVF) and want to chose the best one...totally worth it.  If you don't want to put yourself through the heartache of terminal complications due to defect.  Totally worth it.

  
I *think* you're talking about a different test.  The one the OP is talking about is done around  13 weeks. It is very routine, consists of one blood pull from mom and a high resolution ultrasound measurement of the neck vertebrae.  But it is indeed a bit useless. 

The materials for the test tell you that if your test comes back positive for makers you have some 20% chance that it is a false positive. Similarly, if you test negative there's some equally dump percentage that could be a false negative.  To continually fine tune the test I *BELIEVE* CA takes a small blood draw from the baby after birth and compares it to the initial labwork. 

We went with it purely because it meant we got an extra (free) ultrasound and got to say hi to the baby. 

 

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ganda said:   The best healthcare system in the world is never going to be cheap.
  
Neither is an opaque system, regardless of its relative quality. That part seems like a solvable problem.

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doveroftke said:   Cases like these, which are extremely common, really highlight some of the major issues with the way medical care is billed in this country. None of the proposals from either political party made any attempt to address this type of problem.
   Bingo. All medical providers should be required to be transparent and post their rate card online, or to a central, consumer-oriented database. That way consumers can shop around for medical services. Part of the reason prices are so high, is that it's literally impossible to comparison shop and there's no incentive to medical providers to be price competitive.

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When my wife was pregnant I remember asking what the point of the test was. The doctor sensed what we meant and told us there was no point.

Thanks for posting OP. This is definitely useful info for other folks in your shoes and it's nice to know that by avoiding the test, we were also saved from this billing headache too.

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ganda said:   The best healthcare system in the world is never going to be cheap.
  So why is the US spending so much more than EVERY OTHER COUNTRY on healthcare if our system is so shoddy and sub-par?

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meade18 said:   When my wife was pregnant I remember asking what the point of the test was. The doctor sensed what we meant and told us there was no point.

 

  NIPTs for Downs are great.  Microdeletions?  LOL.  The positive predictive value is often under 10%, so all they do is worry people unnecessarily.

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cestmoi123 said:   The labs massively discount. We had roughly the same situation (cost $8k, not covered, EOB from the insurer said we owed $7k). When we got a bill from the testing provider, it showed (round numbers) $8k cost, less $1k paid by insurance, less $6750 courtesy discount, $250 balance.
Probably be something like that. My wife recently had some blood tests for other reasons and she was told by the provider referring her for the blood test that this would be the case. They'd send a huge bill to our insurance. They'd cover what ever portion of it that they would and the EOB would say we owed what ever was left over but the bill would be pretty small when we got it from the lab. They basically said it was because sometimes insurance would actually pay that much so the lab always billed high to get as much from the insurance as they could.  Makes no sense and horrible situation to be in as a customer but it is what healthcare is now a days, at least here in the US.

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jagec said:   
ganda said:   The best healthcare system in the world is never going to be cheap.
  So why is the US spending so much more than EVERY OTHER COUNTRY on healthcare if our system is so shoddy and sub-par?

  
I was being sarcastic, I thought that was obvious.

Not only do we spend way more, we don't live as long. We pay more for lower quality results. It's pathetic.

Good luck OP. We had a high deductible policy when our daughter was born and I still shake my head in disbelief at the billing shenanigans of the health industry. Care it is not. 

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ganda said:   
jagec said:   
ganda said:   The best healthcare system in the world is never going to be cheap.
  So why is the US spending so much more than EVERY OTHER COUNTRY on healthcare if our system is so shoddy and sub-par?

  
I was being sarcastic, I thought that was obvious.

Not only do we spend way more, we don't live as long. We pay more for lower quality results. It's pathetic.

Good luck OP. We had a high deductible policy when our daughter was born and I still shake my head in disbelief at the billing shenanigans of the health industry. Care it is not. 

  I didn't read it as sarcasm either because this is exactly the talking points from many. 

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doveroftke said:   Cases like these, which are extremely common, really highlight some of the major issues with the way medical care is billed in this country. None of the proposals from either political party made any attempt to address this type of problem.
  I agree with most of your statement, but not the last part. If we were to go to a single-payer/Medicare-for-all system, we wouldn't have this problem. There are some who are advocating for just this system.

BTW, I don't want to derail this thread. This argument is better for the ACA Discussion https://www.fatwallet.com/forums/finance/1580723

Skipping 35 Messages...
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RedWolfe01 said:   
samko said:   
ganda said:   
jagec said:   
ganda said:   The best healthcare system in the world is never going to be cheap.
  So why is the US spending so much more than EVERY OTHER COUNTRY on healthcare if our system is so shoddy and sub-par?

  
I was being sarcastic, I thought that was obvious.

Not only do we spend way more, we don't live as long. We pay more for lower quality results. It's pathetic.

Good luck OP. We had a high deductible policy when our daughter was born and I still shake my head in disbelief at the billing shenanigans of the health industry. Care it is not. 

  I didn't read it as sarcasm either because this is exactly the talking points from many. 

  
I read it as sarcasm, and laughed.  But then I have read enough of the posters "stuff" to get that it WAS.
 
 


You mean erudite wisdom and razor sharp wit, not "stuff".

I've read far too many depressing stories of people who have bankrupted their families with medical bills. In particular a guy who had a brain aneurysm and survived, but the bills destroyed his family financially - "it would have been better if they'd let me die" was the opinion of this now frail man who can provide nothing for his family.

So sad, we'll fix this eventually, but too many families are going to be wiped out by our medical industry before that happens. 

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