Doctor sent labs to out-of-network provider

[CarnivalGal]

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

My primary care, in-network physician recommended blood work. I specifically asked if insurance (United PPO) would cover it. He said they should, but they would double check before doing anything. I had my blood drawn in the office at the same visit. It was all routine blood work which is covered 100% by my insurance company.

I found out today that they sent this blood work to a lab that does not accept my insurance. The total lab bill is $10,300. Yes, you read that correctly. What recourse do I have?

 

[justalayman]

From what i see; none


You would have had to request the name of the lab and verfiied coverage with your provider or told doc to not send the specimens to a lab they are not certain is covered under your insurance. Chances are they would not agree to that as while they check for things as a courtesy, they are not going to guarantee some other provider is covered under your policy.


I would question the amount though. I would also inquire
With your insurance company directly to see if they will cover
Any of that. It may be you will have to pay first and seek whatever the insurance company will cover as
A reimbursement.

 

[CarnivalGal]

From what i see; none


You would have had to request the name of the lab and verfiied coverage with your provider or told doc to not send the specimens to a lab they are not certain is covered under your insurance. Chances are they would not agree to that as while they check for things as a courtesy, they are not going to guarantee some other provider is covered under your policy.


I would question the amount though. I would also inquire
With your insurance company directly to see if they will cover
Any of that. It may be you will have to pay first and seek whatever the insurance company will cover as
A reimbursement.

But I specifically asked about coverage.

Also, upon further review, my insurance is applying their "allowed amount" of $427.57 to my deductible. But the remainder, $10,300 is what is billed to me. How can this be right? How can I be on the hook for $10,000?

 

[justalayman]

Even by what you wrote the doctor did not state with certainty the lab work was covered. It's not even their obligation research it. It's yours.

I specifically asked if insurance (United PPO) would cover it. He said they should, but they would double check before doing anything.

They should.

They would double check, but what were they to do if it wasn't covered?


While I sympathize with your situation as I don't know anybody that hasn't had to deal with something similar,
Although not nearly as great of a scale, ultimately it is up to the consumer to verify what their own insurance covers.

 

[CarnivalGal]

Even by what you wrote the doctor did not state with certainty the lab work was covered. It's not even their obligation research it. It's yours.




They should.

They would double check, but what were they to do if it wasn't covered?


While I sympathize with your situation as I don't know anybody that hasn't had to deal with something similar,
Although not nearly as great of a scale, ultimately it is up to the consumer to verify what their own insurance covers.

But all of the tests WERE covered. They are actually covered 100% under my plan. This is all because they sent the tests to a non-network lab. It is a lab I have never heard of. From what I can tell with my limited internet research, this is a small lab that doesn't accept any insurance.

United was actually relatively helpful, but I need to call on Monday to speak with someone more knowledgeable about my specific plan. But according to her, there may be a clause in my insurance that says if the physician ordering the tests is in-network (he is), then the tests should be covered as in-network, even if the lab is technically out-of-network. If that's the case, then it's a billing issue, and that can be resolved. If that's not the case, then it becomes a problem. The person I spoke to at United was appalled at how much they are billing for routine lab work. She was nice enough to tell me that the Medicare rate for everything I had done is the $427.57. So if it comes down to negotiating, I should aim for that number.

 

[justalayman]

But all of the tests WERE covered. They are actually covered 100% under my plan. This is all because they sent the tests to a non-network lab. It is a lab I have never heard of. From what I can tell with my limited internet research, this is a small lab that doesn't accept any insurance.

United was actually relatively helpful, but I need to call on Monday to speak with someone more knowledgeable about my specific plan. But according to her, there may be a clause in my insurance that says if the physician ordering the tests is in-network (he is), then the tests should be covered as in-network, even if the lab is technically out-of-network. If that's the case, then it's a billing issue, and that can be resolved. If that's not the case, then it becomes a problem. The person I spoke to at United was appalled at how much they are billing for routine lab work. She was nice enough to tell me that the Medicare rate for everything I had done is the $427.57. So if it comes down to negotiating, I should aim for that number.

I don't see how the insurance company can mandate the testing facility be treated as an in network provider. In network providers agree to a heavy billing discount. The insurance company cannot mandate the insurance company agree to any particular payment schedule but regardless, they cannot prohibit the provider from
Balance billing you for whatever the insurance company doesn't pay.


The Medicare rate is a unrealistic low price.

 

[LdiJ]

I don't see how the insurance company can mandate the testing facility be treated as an in network provider. In network providers agree to a heavy billing discount. The insurance company cannot mandate the insurance company agree to any particular payment schedule but regardless, they cannot prohibit the provider from
Balance billing you for whatever the insurance company doesn't pay.


The Medicare rate is a unrealistic low price.

In this case, I think that the Medicare rate is a whole lot closer to reality than 10.3k. I had a whole panel of blood work done a year or so ago and I have no insurance. It cost me less than 500.00 as well. While Medicare rates are quite low we are not talking about a situation where the Medicare rate is only half or even a third of the regular rate. In this case we are talking about a scenario where the Medicare rate is less than 5% of the regular rate. Something is definitely not right here.

Also, I would be making a complaint to the doctor. The doctor needs to be aware of what happened so that he stops using that lab.

 

[justalayman]

In this case, I think that the Medicare rate is a whole lot closer to reality than 10.3k. I had a whole panel of blood work done a year or so ago and I have no insurance. It cost me less than 500.00 as well. While Medicare rates are quite low we are not talking about a situation where the Medicare rate is only half or even a third of the regular rate. In this case we are talking about a scenario where the Medicare rate is less than 5% of the regular rate. Something is definitely not right here.

Also, I would be making a complaint to the doctor. The doctor needs to be aware of what happened so that he stops using that lab.

I don't disagree there. I would surely be looking for a justification of the price charged. It might even warrant contacting the state's attorney general. I'm hearing more and more interest in situations like this where a consumer does not have the option of choosing the outside provider and having to deal with out of network providers and ridiculous fees. It's been happening with hospital visits for a long time and I would like to see somebody figure out how to improve the system.

 

[cbg]

This is a question for the Provider Relations branch of the insurance carrier. It sounds to me as if the doctor violated his contract with United (and I have some inside knowledge on this and how this works).

OP, let United handle it. Call Provider Relations on Monday and follow their instructions. You won't have to pay ten thousand dollars, I promise you that. You did everything you were supposed to do.

 

[justalayman]

This is a question for the Provider Relations branch of the insurance carrier. It sounds to me as if the doctor violated his contract with United (and I have some inside knowledge on this and how this works).

OP, let United handle it. Call Provider Relations on Monday and follow their instructions. You won't have to pay ten thousand dollars, I promise you that. You did everything you were supposed to do.

Can you explain a bit?

Even if the doctor breached his contract, how would it alter the labs right to bill op for the costs of the tests?

 

[cbg]

The lab can bill anything they want. They don't have a contract with the insurance carrier or the patient that says they can't.

However, the doctor does have a contract with the insurance carrier and, unlike most of the time we get this question, the OP DID specifically request that the doctor confirm that the lab would be in-network. Had he not done so, it would be his problem. Since he did, it's now the doctor's. The patient fulfilled his obligation to the contract - he requested that in-network carriers be used. The patient is now protected by his contract and will only have to pay what he is responsible for under that contract. The doctor is the one who breached the contract - he can fight it out with the lab.

That's unless United has changed a great, great deal since it was their name printed at the top of my paycheck.

 

[justalayman]

I disagree. op asked if insurance would cover it. Insurance did cover it to the tune of $400 or so dollars.

 

[cbg]

And OP is not going to be held responsible for the balance.

How long did you work in the insurance industry, jal?

 

[justalayman]

And OP is not going to be held responsible for the balance.

How long did you work in the insurance industry, jal

So what precludes the lab from going after the OP? The insurance is welcome to indemnify op. If insurance
Company per their contract has some right to demand doctor pay the lab bill, fine but regardless of anything involving the insurance; lab has a right to seek payment from op, unless lab and doctor has some contract providing otherwise.

 

[cbg]

So your position is that despite the poster having specifically requested that the work be sent in network, thus doing exactly what we tell people they should have done in other threads, and despite the charges being well in excess of the usual and customary, the poster is going to be held legally liable to pay the charges. Is that what you're telling me?