Doctor sent me to non-network lab

[sportage]

What is the name of your state? NJ

My health insurance is Horizon Blue of NJ. I have a Basic EPO, which turns out to be the same as an HMO. I never knew that because all the info from Horizon never mentions the term HMO. My health insurance card has the PPO logo on it, so I made the mistake of going to a doctor who was listed under PPO coverage but doesn't participate in the HMO.

I called the doctor's office to tell them my health insurance coverage. They said they were in the network & collected my $30 copay at the office. I had a physical & a lot of blood work was done. The lab work was handled by Quest. It turns out that Horizon Blue of NJ only covers lab work done at Lab Corp. I was not asked where to send the blood work, nor was I informed as to who was doing it. I thought the doctor's office should know if they were in-network or not, and that they would send my lab work to the correct lab. I was wrong.

I eventually settled the doctor's bill at a "cash" rate because Horizon wouldn't cover it. It was only after incurring lots of bills that I was informed to the fact that the EPO was really an HMO & Horizon refused to pay.

I just received an EOB for $1800 worth of lab work done by Quest & which Horizon won't pay. If the work isn't done by Lab Corp, they will not pay for it, they said. Now I am frantic because of this huge lab bill. I have not received a bill yet for Quest, but now that they have been denied by the insurance company, they will surely come after me.

Do I have any options other than paying the lab bill in full? The doctor's office led me to believe they were in-network by telling me so on the phone when I made the appointment and by collecting my copay. They sent the blood work to a lab of their choosing, not of mine. I feel very helpless because this is an awful lot of money for me to owe.

Would Quest accept less than the full amount? Is the doctor's office in any way responsible for this situation? I feel as if they erred by telling me I had coverage & then sending my lab work to Quest.

I am sick to my stomach over this situation & I would really appreciate any advice you can give me on this matter. By the way, the doctor's office is in New York because that's where I work. Horizon's HMO says they do not cover doctor visits outside NJ unless it's an emergency - another thing they didn't clarify when I purchased the policy.

Thank you in advance for any help you can give me.What is the name of your state? NJ

[ecmst12]

At what point did you call your insurance company to verify that your chosen doctor was in network before you had the visit? That is what you needed to do. Because as you've learned, doctors offices deal with so many different insurance plans that they can't possibly be expected to keep them all straight, and sometimes they think they participate when they don't, and vice versa.

If you had gone to a participating doctor, and he'd sent your samples to a non-participating lab, you might have a case for either the doctor or your insurance company to pay, since you don't really have any control over it. But you didn't go to a participating doctor, so he really had no obligation to send your samples to a participating lab, and since he didn't even realize that HE didn't participate with your plan, he had no way of knowing that the lab did not participate either.

Moral of the story is, ALWAYS verify coverage/participation with your insurance company, yourself, before receiving any non-emergency treatment.

You owe the bill to quest, but they will probably not insist that you pay it all at once. Call them up and try to work out a payment plan.

[sportage]

I did not call the insurance company to verify the doctor was participating. I went on their web site & looked up his name instead. Unfortunately I was misled by the fact that my EPO is an HMO, not a PPO in spite of the PPO logo on my ID card. I know that I made mistakes - I'm new at this insurance game. This is a policy I purchase on my own because my job has no benefits & I recently graduated college & came off my parents' policy.

I guess I thought the doctor might be somewhat responsible for giving me the false impression that I was dealing with a participating doctor. So he gets to take my copay, do all kinds of tests, run up a large medical bill & leave me holding the bag? That's pretty depressing to me & sounds rather unfair.

Would Quest give me a discount, like they would give the insurance company? It would help a lot if they'd accept a smaller amount, but in a lump sum. Otherwise, I will have to go on a payment play because I just don't make enough money to pay this bill in full any time soon.

Thanks again.

[ecmst12]

You are responsible for your own heathcare. It's your plan, you pay for it, you should make sure you understand it. Like I said, ALWAYS call to verify.

Quest might be willing to give you a discount. Only way to find out is to call and ask.

[TIMMAAYY]

They don't make it easy to figure out, that's for certain. All these ridiculous options for PPO, HMO, EPO, blah blah blah.... good lord. It's just insurance. Why they do that crap is beyond me, other than to make it difficult for the average person to figure out. And when the provider ALSO thinks they are in network... you are hardly to blame.

There are no guarantees, but call the lab and tell them what happened. Negotiate. The doctor did, right? More often than not, they will take less. The bill you are seeing is for the FULL AMOUNT... as if you didn't have insurance... what you are referring to as the "cash rate".

If you had known and a lab within the network had done the work, they would have billed much less for their services, as provided by their contract with the carrier. Don't ever think that you can't negotiate. Always give it a try in a case like this, or in any case where there is a large bill due to a provider outside of what the insurance company is or is not paying to the provider.

Hope this helps.

[sportage]

I haven't received the actual bill from Quest yet, only seen the EOB from Horizon. Frustrating part is that the EOB shows the "allowed amount" to be $345 as if they were going to pay it. When I called Horizon they said they might have paid it & then reversed the charge. Why would they even do that if they knew Quest was out of network? It's all very confusing & suspicious.

When I originally found out that the doctor I saw wasn't in the network, I spoke numerous times with the insurance company & even filed an appeal (which I lost). The thing that kills me is that the insurance company told me to CALL THE DOCTOR to confirm they participate - they told me the last word was with the doctor's office. And the doctor's office said they were in network. I don't think it's possible to win this game with the insurance companies - they do not want to commit themselves on any issue.

Actually Horizon DID pay a smaller Quest bill relating to this doctor's visit, but I don't dare even mention that to them for fear they will reverse that payment. Quest was out of network when they made that payment, yet I was told it was done "as a courtesy". So I feel that they just tell me whatever they want to at the time & I have no recourse.

Once I see the actual bill from Quest, I will have to try for a lower payment.

Thanks for your help.

[ecmst12]

If you had known and a lab within the network had done the work, they would have billed much less for their services, as provided by their contract with the carrier.

Not true. They bill the same. They just ACCEPT the negotiated rate for payment.

It's even possible that Quest will only bill you for the allowed amount, you never know. Quest I'm sure participates with other plans that Horizon offers.

[lealea1005]

I haven't received the actual bill from Quest yet, only seen the EOB from Horizon. Frustrating part is that the EOB shows the "allowed amount" to be $345 as if they were going to pay it. When I called Horizon they said they might have paid it & then reversed the charge. Why would they even do that if they knew Quest was out of network? It's all very confusing & suspicious.

When I originally found out that the doctor I saw wasn't in the network, I spoke numerous times with the insurance company & even filed an appeal (which I lost). The thing that kills me is that the insurance company told me to CALL THE DOCTOR to confirm they participate - they told me the last word was with the doctor's office. And the doctor's office said they were in network. I don't think it's possible to win this game with the insurance companies - they do not want to commit themselves on any issue.

Actually Horizon DID pay a smaller Quest bill relating to this doctor's visit, but I don't dare even mention that to them for fear they will reverse that payment. Quest was out of network when they made that payment, yet I was told it was done "as a courtesy". So I feel that they just tell me whatever they want to at the time & I have no recourse.

Once I see the actual bill from Quest, I will have to try for a lower payment.

Thanks for your help.

When you called the Doctor's office you asked them if they participated In Horizon PPO, which they do. How were they to know you're covered by an HMO/EPO contract?

In any event, wait to receive an actual bill from Quest before calling them. Ecmst12 is correct.

[sportage]

When I called the doctor's office, I told them I had an Horizon EPO, not a PPO. I am sure of that because I had the card right in front of me. They said they participated.

The blood was drawn in the doctor's office, then sent out to Quest. At no time was I given a choice of labs - that was the doctor's choice, not mine. Can the doctor just send the lab work anywhere they want, and then if it's not covered by my insurance, can I get stuck with the bill? What gives the doctor immunity in this situation?

Does this happen a lot, where doctors incur uncovered lab bills on behalf of their patients? I can't help but feel that the doctor's office has some liability on this bill.

The bill from Quest isn't here yet - all I can do is wait & see what happens. I'm still curious as to why Horizon showed a negotiated rate on an EOB if they didn't intend to pay. Sort of like rubbing salt in the wounds.

[moburkes]

When I called the doctor's office, I told them I had an Horizon EPO, not a PPO. I am sure of that because I had the card right in front of me. They said they participated.

The blood was drawn in the doctor's office, then sent out to Quest. At no time was I given a choice of labs - that was the doctor's choice, not mine. Can the doctor just send the lab work anywhere they want, and then if it's not covered by my insurance, can I get stuck with the bill? What gives the doctor immunity in this situation?

Does this happen a lot, where doctors incur uncovered lab bills on behalf of their patients? I can't help but feel that the doctor's office has some liability on this bill.

The bill from Quest isn't here yet - all I can do is wait & see what happens. I'm still curious as to why Horizon showed a negotiated rate on an EOB if they didn't intend to pay. Sort of like rubbing salt in the wounds.

They likely do participate in Horizon EPO. However, there are hundreds of Horizon EPO programs.

Yes, the doc can send your blood to whichever lab it normally uses. Again, they aren't required to know, nor should they, every single patient's insurance coverage, no matter how many times you ask the question.

Does it happen a lot? I don't know.

[TIMMAAYY]

Not true. They bill the same. They just ACCEPT the negotiated rate for payment.

It's even possible that Quest will only bill you for the allowed amount, you never know. Quest I'm sure participates with other plans that Horizon offers.

Not as far as the one receiving the bill is concerned. Go to any doctor and tell them you don't have insurance. You will get the "whole" bill.

Doing the same thing WITH insurance, you will only get the bill as allowed by the carrier, or the negotiated rate. The doctor may file the "whole" bill with the insurance carrier, but the actual bill received by the patient on their EOB will be the negotiated rate.

[cbg]

Not as far as the one receiving the bill is concerned. Go to any doctor and tell them you don't have insurance. You will get the "whole" bill.

For the most part I agree with this. However, a couple of years ago I was in need of some DME that was not covered on my insurance. Upon learning this, the provider cut the bill by almost two thirds.

While rare, it does happen.

[TIMMAAYY]

Right. Sometimes you get a break, for example, like I do at the chiropractor. I just pay cash, and I get a break because they have their money at the time of service, and they don't have to do any paperwork for billing, etc. It's much more efficient for them.

It's actually slightly less than the negotiated rate ( partly because I pay cash, and partly because I am a frequent flyer ).

[mrnec]

State of Texas

My wife and I are having our 2nd child together.
She verified her OBGYN is covered under my new insurance plan "UNITED HEALTHCARE".
She had a pregnancy confirmation test and blood drawn on 12/4.
She provided our insurance card after services rendered and paid the requested $30 Copay.
She went back to the dr's office on 12/17 to visit with the doctor.
She was not asked to pay a copay as the billing would be drawn up for the entire pregnancy.
This week i got a bill from QUEST DIAGNOSTICS for $1000+
Apparently, QUEST submitted their claim to AETNA and it was declined.
It appears the doctor's office made a mistake in submitting the blood work to an OUT OF NETWORK provider when they were provided our new insurance.
The doctor's office suggested we call our current insurance to see if they will cover the blood work.
I do not see why i would have to pay any additional $$ money for the doctor's office mistake.

Is this something they are responsible for?

[Indiana Filer]

State of Texas

My wife and I are having our 2nd child together.
She verified her OBGYN is covered under my new insurance plan "UNITED HEALTHCARE".
She had a pregnancy confirmation test and blood drawn on 12/?

Mr Nec, you need to start your own thread instead of adding your question onto an existing thread.