Insurance company denied coverage for $1300 blood work - what now?
June 25, 2013 5:05 PM Subscribe
I had a blood test done to check for a gene mutation that my family recently discovered we may have. It was just blood work from an in-network lab so I assumed it would be covered, per my "schedule of benefits." Today I received a letter from my health insurance provider saying this testing is not covered. The cost is $1300 and I definitely do not have $1300. I haven't been billed by the blood lab, but I imagine that it's coming soon and I will be fucked. My insurance company also said that these limitations on testing are available to view in their policy bulletins, of which I have obviously never checked or even knew existed -- I was going entirely off my "schedule of benefits" and I believed that in-network blood work was just my co-pay. More details below:
My insurance company's letter specifically said it would be covered if I had some specific complications that arise from the mutation already, which I don't. They said a family history of these complications in individuals under 50 would allow it to be covered -- my grandmother died of a complication that probably arose from this mutation but she was 60. The problem did start earlier, but I don't know if she was 50 or younger when it first happened, or if any medical records even exist of it anymore since it was so long ago (30+ years). My insurance company also said that it would be covered if I had elevated levels of a specific amino acid in my blood, but I don't think my doctor had tested for that -- if I tested it now and it was elevated, it was still tested after I had the initial gene mutation test, so I'm not sure if that would help me or not. I mostly got the test because my sibling figured out she had it after her doctor thought it might be contributing to some medical problems she's been having (problems which are not recognized by my insurance company and problems that are not what my grandma died from). The bottom line is that they consider this test "experimental" and not medically necessary.
What can I do? Can I work with my doctor to have him say he found it medically necessary? Or is my insurance company going to require medical records of my family members if I want to argue I have a family history of problems related to this mutation? Can I get the blood lab to waive or reduce what they charge me? Does an appeal to my health insurance company even stand a chance? They claim appeals are handled externally and not by the insurance company. Any thoughts on how to avoid paying $1300, or frankly, anything above like $200, would be helpful. As it is, I am on COBRA paying $400 a month for this health insurance because I was laid off quite a while ago.
My insurance company's letter specifically said it would be covered if I had some specific complications that arise from the mutation already, which I don't. They said a family history of these complications in individuals under 50 would allow it to be covered -- my grandmother died of a complication that probably arose from this mutation but she was 60. The problem did start earlier, but I don't know if she was 50 or younger when it first happened, or if any medical records even exist of it anymore since it was so long ago (30+ years). My insurance company also said that it would be covered if I had elevated levels of a specific amino acid in my blood, but I don't think my doctor had tested for that -- if I tested it now and it was elevated, it was still tested after I had the initial gene mutation test, so I'm not sure if that would help me or not. I mostly got the test because my sibling figured out she had it after her doctor thought it might be contributing to some medical problems she's been having (problems which are not recognized by my insurance company and problems that are not what my grandma died from). The bottom line is that they consider this test "experimental" and not medically necessary.
What can I do? Can I work with my doctor to have him say he found it medically necessary? Or is my insurance company going to require medical records of my family members if I want to argue I have a family history of problems related to this mutation? Can I get the blood lab to waive or reduce what they charge me? Does an appeal to my health insurance company even stand a chance? They claim appeals are handled externally and not by the insurance company. Any thoughts on how to avoid paying $1300, or frankly, anything above like $200, would be helpful. As it is, I am on COBRA paying $400 a month for this health insurance because I was laid off quite a while ago.
Definitely ask the office if they can appeal, though it might not/probably won't work. But it's worth a shot.
Do the lab and the doctor's office bill separately, or are they part of the same practice/institution? If the latter, you might have luck swearing up and down that you only did the test because the doctor gave you the impression the lab services would be covered in-network. Complain a lot to whoever you can- patient services, your friend the VP of Health Whatever. Call every day. Be so annoying that they write off the bill just to get rid of you.
If all this fails, see if you can work out a payment plan where you pay a teeny amount a month.
posted by ThePinkSuperhero at 5:25 PM on June 25, 2013
Do the lab and the doctor's office bill separately, or are they part of the same practice/institution? If the latter, you might have luck swearing up and down that you only did the test because the doctor gave you the impression the lab services would be covered in-network. Complain a lot to whoever you can- patient services, your friend the VP of Health Whatever. Call every day. Be so annoying that they write off the bill just to get rid of you.
If all this fails, see if you can work out a payment plan where you pay a teeny amount a month.
posted by ThePinkSuperhero at 5:25 PM on June 25, 2013
You can ask your physician write a letter of medical necessity that would give the insurance his reasoning for ordering the test. Give him the information you presented here to help him know what to include. It still may not change what your insurance will cover, but it's definitely worth a try. If it doesn't work, you can negotiate with the providers as the folks outline above.
posted by goggie at 5:33 PM on June 25, 2013 [1 favorite]
posted by goggie at 5:33 PM on June 25, 2013 [1 favorite]
Yep, always start by appealing, especially if you can get your doctor's office involved (make sure you specifically ask to speak to the office manager to get the ball rolling). This likely isn't the first time they've seen this sort of thing happen, so they should know the proper wording, codes, etc. that might help.
Nthing that if that doesn't work, payment plans are always possible to work out for small monthly amounts. This is (tragically) a not-uncommon situation, so most labs/doctor's offices/hospitals do have a system in place to set this up automatically. And it's much better for everyone involved to pay them $25/month for several years than to let it go to collections.
posted by scody at 5:36 PM on June 25, 2013 [1 favorite]
Nthing that if that doesn't work, payment plans are always possible to work out for small monthly amounts. This is (tragically) a not-uncommon situation, so most labs/doctor's offices/hospitals do have a system in place to set this up automatically. And it's much better for everyone involved to pay them $25/month for several years than to let it go to collections.
posted by scody at 5:36 PM on June 25, 2013 [1 favorite]
Immediately call the office that did the labwork. I am thinking you were billed by mistake -- I certainly have been for similar tests and the billing specialists were the ones who could quickly tell whether a bill was legit or initiated by accident.
posted by These Birds of a Feather at 5:48 PM on June 25, 2013
posted by These Birds of a Feather at 5:48 PM on June 25, 2013
Ask your doctor's billing staff which ICD-9 codes were submitted for the labwork. These codes should indicate [family history of grandma's cause of death] and [family history of genetic mutation] as you've indicated above, possibly with other codes. These codes are part of determining medical necessity.
Does the letter from the insurance company clearly state 'you owe the laboratory $1300' or 'patient responsibility $1300'? If not, it is possible that the insurance will discount the services to their in network contracted rate with the lab. That could leave you owing much less than $1300. It is possible that you owe essentially the amount the insurance would have paid under their contract with the lab if they were paying on these services. If this discounting wasn't done, this is something you could ask of your insurance company. The lab will likely negotiate on their own terms.
Insurance company online portals (where available) usually have appeal instructions, benefits, and claim specifics. If you haven't already, try setting up a login to access this info.
posted by txtwinkletoes at 6:02 PM on June 25, 2013
Does the letter from the insurance company clearly state 'you owe the laboratory $1300' or 'patient responsibility $1300'? If not, it is possible that the insurance will discount the services to their in network contracted rate with the lab. That could leave you owing much less than $1300. It is possible that you owe essentially the amount the insurance would have paid under their contract with the lab if they were paying on these services. If this discounting wasn't done, this is something you could ask of your insurance company. The lab will likely negotiate on their own terms.
Insurance company online portals (where available) usually have appeal instructions, benefits, and claim specifics. If you haven't already, try setting up a login to access this info.
posted by txtwinkletoes at 6:02 PM on June 25, 2013
We got a lab bill yesterday. $700 retail. $90 at our insurance company's contracted price. So definitely make sure you are getting the contract price.
posted by COD at 6:56 PM on June 25, 2013
posted by COD at 6:56 PM on June 25, 2013
I paid insurance claims for five years. Please calm down. It is a highly regulated industry and very bureaucratic. The first denial letter is often sent by some gumby with an entry level job, drowning in a sea of information overload. Especially for situations that come up infrequently, this can mean they just are not very familiar with it and it may not be a correct denial.
Yes, appeal.
Yes, your doctor's word carries more weight than yours. Get a letter from your doctor.
Ask the insurance company to send you information in writing explaining what documentation/facts it would take to cover this. Start trying to come up with those documents. It may just be a case of they need more records. I requested lots of records as part of my job.
Be unfailingly polite to every person you speak with at the company. They are only doing their job. They don't hate you. They aren't out to get you. They get hated on a lot (and cussed out, threatened, etc) and to whatever degree they have decision-making latitude, it is in your best interest to be looked upon more kindly than the last asshat they spoke with just before your phone call. It won't mean a "yes" in cases where it clearly is not covered but can tilt things in your favor in grey zone areas.
Last, view it as you and the employee against the bureaucracy rather than you against the employee. Paying insurance claims can be very frustrating. The employees are often as frustrated as the customer. It isn't even necessarily the company that is the problem. Sometimes, the problem is federal laws and regulations. I always was happy to help solve a customer's problems. It made my day to help someone get necessary treatment covered. But I still routinely was assumed to be The Bad Guy when I called after the last three letters failed to get me the info I needed because it is all written in legalese. Not my choice. I just worked there.
Good luck.
posted by Michele in California at 7:14 PM on June 25, 2013 [7 favorites]
Yes, appeal.
Yes, your doctor's word carries more weight than yours. Get a letter from your doctor.
Ask the insurance company to send you information in writing explaining what documentation/facts it would take to cover this. Start trying to come up with those documents. It may just be a case of they need more records. I requested lots of records as part of my job.
Be unfailingly polite to every person you speak with at the company. They are only doing their job. They don't hate you. They aren't out to get you. They get hated on a lot (and cussed out, threatened, etc) and to whatever degree they have decision-making latitude, it is in your best interest to be looked upon more kindly than the last asshat they spoke with just before your phone call. It won't mean a "yes" in cases where it clearly is not covered but can tilt things in your favor in grey zone areas.
Last, view it as you and the employee against the bureaucracy rather than you against the employee. Paying insurance claims can be very frustrating. The employees are often as frustrated as the customer. It isn't even necessarily the company that is the problem. Sometimes, the problem is federal laws and regulations. I always was happy to help solve a customer's problems. It made my day to help someone get necessary treatment covered. But I still routinely was assumed to be The Bad Guy when I called after the last three letters failed to get me the info I needed because it is all written in legalese. Not my choice. I just worked there.
Good luck.
posted by Michele in California at 7:14 PM on June 25, 2013 [7 favorites]
Get the doctor's office to help you. Trust me, they want to!
posted by St. Alia of the Bunnies at 7:29 PM on June 25, 2013
posted by St. Alia of the Bunnies at 7:29 PM on June 25, 2013
Listen to Michele. If that does not get it paid, work with the lab. Medical providers of all kinds are used to dealing with self-pay patients, and will often reduce the charge drastically to get it resolved.
posted by yclipse at 8:20 PM on June 25, 2013
posted by yclipse at 8:20 PM on June 25, 2013
Talk to the doctors first, that might help. My kids' pediatrician had us make an appointment for a 2.5 year WCV without telling us (as they were supposed to, I later found out) that not all insurance plans cover it. So when I got the bill later, they gave me a significant discount on it. Not exactly the same scenario, but it can't hurt. I think they should have told you it might not have been covered. I don't think those kinds of tests are covered all that often.
posted by pyjammy at 8:32 AM on June 26, 2013
posted by pyjammy at 8:32 AM on June 26, 2013
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