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Health insurance deductible question.
June 3, 2014 12:05 PM   Subscribe

Say I have a 2500$ deductible, and I get blood work totaling over 2500$ which the diagnostic company has billed the insurance company for, but agreed not to bill me for ...

Is the fact that it is currently counting toward my deductible something that often happens? I don't necessarily want to bring this to the attention of my insurance company by asking questions if its a common occurrence. I also do not want to get screwed if it drops off in the coming months.

Thanks in advance!
posted by phox to Health & Fitness (20 answers total)
 
If you have a $2,500 deductible which has not been met (and there is no exclusion from the deductible for the blood work), I doubt that it will be paid by the insurance company, or, if it is paid, that they won't get it back from the diagnostic company, once they determine the error, which will then bill YOU for the amount.

Honestly, I can't imagine why the diagnostic company would tell you they wouldn't bill you if they were aware that you hadn't met the deductible for this policy period, they should know better or it's some type of scam (which, I sort of doubt).

The only way to determine the situation is to ask the insurance company, otherwise you would be best to put away $2,500 to pay the bill if/when it arrives.
posted by HuronBob at 12:11 PM on June 3 [1 favorite]


Here's the thing, you need to wait to get your Explanation of Benefits. The lab may charge people off the street $2,500 for blood work, but your insurance may have a negotiated rate which would be half of that, or less.

Also, yes, any charges that are covered by your insurance count towards your deductible.

What will happen is that the lab will submit your insurance information to the insurance company. They'll get paid whatever is over the amount of your deductible by the insurance company, the Lab will then bill you for the remainder.

If it's only $1,250, then that's what you'll pay.
posted by Ruthless Bunny at 12:11 PM on June 3 [4 favorites]


"Also, yes, any charges that are covered by your insurance count towards your deductible. " This is incorrect, funds paid by the insurance company do not count towards your deductible. Only funds paid out of pocket by yourself count.
posted by HuronBob at 12:13 PM on June 3 [7 favorites]


I'm confused by the part where they agreed not to bill you. Presuming that if the insurance company didn't pay, they weren't going to let you have a freebie on this.

Perhaps the lab company did not know that you were on a high deductible plan when you had the discussion with them about not billing you for the blood work. It sounds like you owe them $2500 - I'd call them to negotiate it rather than asking your insurance company about it.
posted by treehorn+bunny at 12:14 PM on June 3


What typically happens (or at least has happened to me) is that the insurance company will pay the bill from the provider, and then after some internal delay and general number-crunching, will figure out that you haven't hit your deductible for the year and will send you a bill for the $2500.

Sometimes they might realize that ahead of time and refuse to pay the provider but in general I think typically they pay first and then sort it out with you later on.

And yeah, as Ruthless Bunny points out it may be the case that $2500 is the "street price" for schlups without insurance, but that due to a deal your insurance provider has cooked up, the actual price of your treatment actually ends up being less than that (which may involve some back-and-forth between the provider and the insurance company). The insurance company can't charge you more than they actually end up paying the provider. So if they negotiate it down to $1200 via some prearranged cost schedule, then you'll only end up owing $1200. So it is good (for you) to have the provider bill the insurance company rather than having you pay them directly.

I'd make sure you have $2500 for when the bill arrives, and don't count on the insurance company just "forgetting" that you haven't paid your deductible. You'll definitely owe something, not more than $2500 but it might be exactly that.
posted by Kadin2048 at 12:16 PM on June 3


"Also, yes, any charges that are covered by your insurance count towards your deductible. " This is incorrect, funds paid by the insurance company do not count towards your deductible. Only funds paid out of pocket by yourself count.

To clarify, if these labs are typically covered by your insurance, in that if you had reached your deductible they would be paid, then if you paid for them out of pocket, it would contribute to your deductible.

If the labs aren't covered, say they're experimental, or not ordered by your PCP, or for some other reason would NOT be covered by your insurance, then even if you pay for them out of pocket, they won't count towards your deductible.
posted by Ruthless Bunny at 12:17 PM on June 3


They'll bill the insurance company.

The insurance company will pay the amount (if any) over $2500.

Then the lab will bill you for whatever the insurance company didn't pay.

Then you'll have to pay that.

The lab is going to get paid, either by you or the insurance company. If you haven't met your deductible yet, the insurance company knows that and will not pay anything until after you have paid $2500 out of pocket.
posted by rabbitrabbit at 12:18 PM on June 3 [3 favorites]


Another factor to consider: sometimes labwork is covered by a copay and is not subject to the deductible. You should check your policy to see how it works for you.
posted by something something at 12:22 PM on June 3 [1 favorite]


The only scenario I see where your insurance will cover the $2500 in lab tests before you hit your deductible is if they cover preventative care and the lab tests were ordered as part of that (say, your annual physical).
posted by Dragonness at 12:23 PM on June 3 [1 favorite]


Yes, exactly right, UNLESS the lab work is covered before you meet your deductible as an exception. But the lab is going to get paid, either by you or the insurance company. They're not going to just not bill you if the insurance doesn't pay some or all of it.
posted by rabbitrabbit at 12:26 PM on June 3


Phox, they are just saving themselves money and saving you confusion by not billing you until they know for sure how much you will need to pay.

Here's the alternate scenario, which I get all the time:

1. I go for medical care.
2. A few weeks later I get a bill from the provider which I ignore.
3. A few weeks after that I get a confusing explanation of benefits from my insurance company. This explains what the negotiated rate is for the medical service, how much the insurance company will pay, and how much I need to pay. (The negotiated rate is the actual cost based on prior agreement between the insurance company and the provider. It is almost always less than the amount of the bill I received in step 2.)
4. A few weeks after that I get another bill from the provider for the amount I owe, which corresponds to the amount given in step 3.

Your provider is skipping step 2, which is great. You'll get a bill eventually.
posted by alms at 12:28 PM on June 3 [1 favorite]


Every year my doctor does a very comprehensive panel from company called Health Diagnostic Laboratory. This is also the first year I had a deductible at all. I expressed my concerns with her over the cost and she told me I would not get billed and if I did, to call them and they would take care of it.

I have gotten the claim forms from the insurance company itself, but never billed from HDL or the doctor. I know my insurance will cover some preventative blood panels, but according to the claim forms, there was A LOT not covered. I dread calling the insurance company, I seem to get different information every time I call.

Edit: This was from blood work taken 5 months ago.
posted by phox at 12:30 PM on June 3 [1 favorite]


I find it highly implausible that the diagnostic company has said they won't bill you. If it is currently counting toward your deductible, that means they've submitted a claim to your insurance company, and it shouldn't ever drop off. (I've never had a charge drop off counting toward my deductible, even when a hospital my wife visited screwed up a procedure and the hospital agreed not to bill me for it; I never saw a bill but my insurance still counted the cost toward my deductible.) Maybe they've agreed to write off the cost of the blood work, but I'd expect that more for a $20 lab test than a $2,500 lab test. It's more likely that they didn't know you hadn't yet met your deductible. You'd be best saving off that $2,500 in your HSA over the next few months. (You DO have an HSA, right?)

Here is how high deductible health plans usually work.

What generally happens if you have not met your deductible:

* Diagnostic Company sends a bill for $2,500 to Insurance Company.
* Insurance Company says "No, you've agreed to only charge our customers $674 for that blood work."
* Insurance Company adds $674 toward the amount you've paid out of pocket for medical bills since January 1, 2014, and counts that toward your deductible.
* Insurance Company tells Diagnostic Company, "Phox has not met the deductible, therefore we are not paying you anything. Please send Phox a bill for $674."


What generally happens if you are approaching your deductible:

Say for the sake of argument you've paid $1,850 out of pocket for your medical bills so far this year.

* Diagnostic Company sends a bill for $2,500 to Insurance Company
* Insurance Company says "No, you've agreed to only charge our customers $674 for that blood work."
* Insurance Company adds $674 to the amount you've paid out of pocket for medical bills since January 1, 2014. It sees this amount exceeds $2,500: it is $2,524. You've now exceeded your deductible by $24.
* Insurance Company pays Diagnostic Company $19.20 (80% of $24). You are responsible for the remaining 20%.
* Insurance Company tells Diagnostic Company, "Please send Phox a bill for $654.80."

What generally happens if you've already met your deductible:

* Diagnostic Company sends a bill for $2,500 to Insurance Company
* Insurance Company says "No, you've agreed to only charge our customers $674 for that blood work."
* Insurance Company adds $674 to the amount you've paid out of pocket for medical bills since January 1, 2014.
* Insurance Company pays Diagnostic Company $539.20 (80% of $674). You are responsible for the remaining 20%.
* Insurance Company tells Diagnostic Company, "Please send Phox a bill for $134.80."

Then there is your out-of-pocket maximum for the year. The insurance company covers 100% (not 80%) of the amount over your out-of-pocket maximum.
posted by tckma at 12:33 PM on June 3 [3 favorites]


Ah, your provider is either an idiot or very generous.

Give her a call.
posted by fontophilic at 12:33 PM on June 3 [3 favorites]


Definitely follow-up with the provider's office on what, if any, balance you owe them. If the provider told you she's not going to hold you responsible, you want to make sure the billing office knows that.
posted by ThePinkSuperhero at 12:44 PM on June 3


Beware generalities about deductibles. Sometimes policies have multiple deductible amounts such as individual vs family or treatment vs drugs, etc.

In this case, I suspect what you were told was meant to mean "we will send the bill to the insurance company first."
posted by SemiSalt at 2:25 PM on June 3


The alternative take is that your provider is neither an idiot nor generous, but on the take.

Doctor orders testing that costs $3,000 (i.e. they bill insurance companies $3,000.) The lab has a cash price of $400 (i.e. if you have no insurance you would pay $400) The actual cost of the labs is somewhere less than $400 so they still get their profit. The lab provides a referral fee (highly illegal) to the doctor and explains to the doctor that as long as they use this lab the patient will never be billed the difference.

This is a great way for doctors to help patients meet their deductibles quickly so that the patient will be more willing to agree to more expensive treatment/tests in the future because "hey, I've already met my deductible."
posted by Broken Ankle at 2:30 PM on June 3 [2 favorites]


What tckma said. Exactly. The provider will bill your insurance company, the insurance company will say "phox has a $2500 deductible, but our allowable amount for this is $674 so please charge phox that amount". Approximately 6-12 months later, you will get a bill for $674 from the provider and you will have to pay it. Seriously, it takes a long time. Just because you're 5 months out does not mean you're in the clear and not going to get a bill. I had tests in my 10th week of pregnancy that I didn't get a bill for until the baby was six months old. I had some tests done in January that I just got a bill for last week. I have a $3000 deductible so I've been there. No one screwed up, you'll get the bill eventually…
posted by echo0720 at 6:01 PM on June 3


I've been lied to by providers before too. You'll be billed eventually.
posted by flimflam at 6:51 PM on June 3


You are always free to call your insurance and ask for your benefits for blood work/ diagnostic testing, and they will let you know what those benefits are.

Are you sure the lab stated that they weren't going to bill you at all? Or just not bill you for the non covered charges? Or the not balance bill you if you're seeing at out of network provider? If the entire bill is applied toward your deductible and that provider doesn't charge you, they'll be in violation of their contract with the insurance company and can lose the contract. (not to mention lose a lot of money in the long run, if I were you I would double check that what you heard the provider say about your bill isn't just want you wanted to hear)

Also, seeing your update: please call the billing office and politely tell them about the conversation you had with the doctor and the staff can confirm this with the doctor. This way you can make sure your account is handled properly.
posted by Attackpanda at 7:33 PM on June 3


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