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Pre-authorization has not been done for lab test. Cigna do not pay the bill.

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el12305

Junior Member
What is the name of your state (only U.S. law)? Virginia

Hello all! I was hoping that someone could give me an advice on the following situation.

A month ago I went to OB for an annual checkup. During the visit she offered a prenatal testing because I mentioned that I m thinking about having a baby. The test includes some genetic testing. I addressed my concern about gen tests being expensive (as I heard) and she said that the very basic one always are covered by insurances. So I agreed. They took my bloodwork right there at the office and then sent them to another lab that did the tests.

A couple of weeks later I found out that the lab submitted a claim to my insurance for over $4000. At some point I called the insurance (worrying that the claim took long time to be processed - it's still under processing). They told me that at this time my patient responsibility is about $200 (which is fine). But they also told me, that they did not pay for gen tests and those amounts have been added to negotiated thing, because the health provider did not obtain prior authorization and technically it's their fault.

Now my question is the following. I have Cigna PPO. The doctor who prescribed tests is out-of-network, but the lab is in-network. My insurance policy states that for in-network it's the health professional should obtain prior authorizations. And for out-of-network - it's my responsibility.
So at this point I m confused - was it my error or the lab who did the tests should have obtained that authorization?


I am completely lost and stressed now. As being new to the whole system (foreigner) I kind of relied on doctor's confidence about telling that basic gen tests are covered. And I do not know what to do, if the lab will decide to bill me for the amount that has not been paid for those genetic tests, because it will be over $2000.

Please, any advice is appreciated.
 


FlyingRon

Senior Member
It is ALWAYS your responsibility to get the preauths when it is required. A lot of in-network labs and imaging places are smart enough to know to tell you to go get the pre-auth before they do the tests (enhances their chances of getting paid), but they will NOT do the preauth themselves (they just tell you to do it) nor is it their responsibility to warn you to do so.

What you can do is to beat on the insurance companies customer support. Sometimes they will accept what would have been allowed with a preauth to be covered even if you didn't.
 

el12305

Junior Member
It is ALWAYS your responsibility to get the preauths when it is required. A lot of in-network labs and imaging places are smart enough to know to tell you to go get the pre-auth before they do the tests (enhances their chances of getting paid), but they will NOT do the preauth themselves (they just tell you to do it) nor is it their responsibility to warn you to do so.

What you can do is to beat on the insurance companies customer support. Sometimes they will accept what would have been allowed with a preauth to be covered even if you didn't.
Thank you for your reply. I understand it now, that I had to call insurance in advance. I guess I made a huge mistake :(

But if my EOB states my responsibility as $200 and not covered genetic tests have been added to a negotiated amount ( as I have been told by Cigna representative, because the claim is still in progress - hopefully that won't change), will that mean, that the lab most likely will bill me for those not paid gen tests?
 

el12305

Junior Member
Sorry, the crystal ball is out being cleaned this week.
There is no need to be sarcastic. I m just trying to learn as much as I can about my situation. I do understand, that I should have done it before.

I will rephrase my last question. If that happens that when my claim will be completed and the Patient Responsibility will be a certain number in my EOB, does the Lab has a legal right to bill me over that patient responsibility for not covered gen tests?
 
Last edited:

cbg

I'm a Northern Girl
That depends on the exact wording of your insurance policy, which I have not read. This is not a matter of statutory or even case law; this is a matter of contract.

These are questions you will need to ask of your insurance company, when and if you are billed by the lab.
 

el12305

Junior Member
That depends on the exact wording of your insurance policy, which I have not read. This is not a matter of statutory or even case law; this is a matter of contract.

These are questions you will need to ask of your insurance company, when and if you are billed by the lab.
Ok, thank you for your help. I will call my insurance to try to find out.
 

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