CoPay

[MA_tenant]

What is the name of your state (only U.S. law)? MA

We have a new insurance plan and the plan says --
Office Care -- 100% after $X Copay

Lab & X Ray -- 100% No Copay

I recently had a blood work at doctor's office . There was no doctor visit and no doctor service. Just the blood work.

The insurance applied the CoPay citing that it was in doctor's office (Office Care). Is that correct ?

[cbg]

That depends on how the doctor's office coded the visit when they submitted the bill.

[ecmst12]

If you went to a freestanding lab to get the blood draw, there would be no copay. Because it was done in the office, there was probably an office visit charged, and that's not inappropriate.

[MA_tenant]

I am tending to believe insurance companies are fools and want to waste money.
If they charge a copay for a office visit even if it is just to draw blood, I would possibly make a doctor visit too from next time just to make sure insurance gets a bill from doctor as well

[ecmst12]

The doctor DID charge an office visit. That's why the copay applies.

[MA_tenant]

Originally Posted by ecmst12

The doctor DID charge an office visit. That's why the copay applies.

No the Doctor DID NOT charge an office visit. There are 3 lines in the bill and EOB corresponding to 3 different blood test. The Copay is mentioned against one of the blood test.

[cbg]

Okay, let's try this again.

When a doctor submits a bill to an insurance company, there are a series of standard codes that he includes on the bill IN ADDITION to the charges.When I say standard codes, I mean that the same codes are used by every doctor in the country to every insurance company in the country.

Regardless of whether or not there is a line item charge that says, Office Visit, if he has included on the bill the code that translates to Office Visit, then as far as the insurance company is concerned, any office visit copay applies.

And yes, that is right.

[justalayman]

this sounds like it is maybe something like my doctors office. Within the office, they have a blood sucker and an x-ray department. They are part of the same med group but are not part of the docs office. If I have blood drawn, it is not by my doctors personnel. Same with x-rays.

Due to this situation, if I have blood sucked or x-rays, they are treated just the same as if I went to a totally different facility.

in my case, the doctor would only be mentioned on the EOB as a reference as to whom the tests were ordered by if at all. There is no billing filed by the actual doctor.


So, MA, under provider (on the EOB) who does it list?

[ecmst12]

Does it show the procedure codes for the visit? Can you post them?

If there truly was no office visit charged (codes beginning with 99), then maybe it's a mistake. Did you call your insurance company and ask them?

[lealea1005]

Originally Posted by ecmst12

Does it show the procedure codes for the visit? Can you post them?

If there truly was no office visit charged (codes beginning with 99), then maybe it's a mistake. Did you call your insurance company and ask them?

In addition...some insurance companies will kick out the 99211 (assuming that is the visit code), even with a modifier, if it's listed with the venipuncture code 36415. They might still charge a co-pay/co-insurance for 36415, as well.

OP, as ecmst already asked, please list the codes on your EOB. It will help us all.

[MA_tenant]

Thanks everybody for the help. I understand the copay is a small amount but I will need such blood work at regular interval and do not want to pay something which I am not supposed to.

Here are the Procedure codes in the bill --

84443
80061
80076

There is another line item for Venipuncture -- 36415 which has been TOTALLY rejected by Insurance saying "The charge for this service is not payable because it is considered part of another procedure performed on the same date of service. You are not responsible for this amount" . The Provider tried to bill this amount to me (in addition to CoPay) but retracted when I argued they are a contracted provider of Insurance and need to take it up with Insurance.

I contacted the insurance (in fact, appealed) and they say since the service was done in Doctor's office, Copay applies. Looks like they want to emphasize on "Where the service is performed" rather then " What the service is". Wonder if a Doctor sees me in a Lab will they waive the Copay ?

[ecmst12]

A doctor wouldn't see you in a lab so that makes no sense.

If your insurance policy says copay applies based on the place of service rather then the services performed, then that's the way it is. I'd say it's unusual, but not unheard of, and certainly legal.

It is normal and common for venipuncture to be denied when they are also billing for the tests. If they sent the tests out and did not bill for them but ONLY the venipuncture, most likely it would have been paid.

[MA_tenant]

Originally Posted by ecmst12

A doctor wouldn't see you in a lab so that makes no sense.

Actually, the insurance explanation in reply to Appeal also says that if the Lab Service is performed in a hospital outpatient setting, there is no copay. So the same argument remains valid -- a doctor can see in hospital outpatient setting ... will they waive the copay ?

If your insurance policy says copay applies based on the place of service rather then the services performed, then that's the way it is.

They say so but did not support with policy words even though I specifically requested.