[QUOTE=jwmc1701;1921420]Unfortunately this is a scam some physician's offices run, claiming that they had no idea Lab X didn't take your insurance and better yet, they probably have a financial interest in it or they're splitting the reimbursement.
[B]It is illegal for the Physician to have a financial interest in the lab/x-ray/diagnostics he/she refers to. You consipracy theorists never cease to amaze me :rolleyes:[/B]
Almost all PPO contracts have a clause which states that a [U]physician is supposed to use [/U][U]every effort to use another in-network physician, facility, lab, etc[/U]. This is forgiven more in a facility setting and especially in emergencies and in-patient stays but there's no real excuse for it in an office. Their claim is that they always can't keep track of which labs, etc. accept what insurance but you know what? That's what they have office staff for. To keep track of those things.
[B]Seems to me that every effort WAS made. This is the only lab that performs the test.
But that being said, the PPOs will rarely do anything to a provider that doesn't use 'every effort' to refer the patient to another in-network provider/facility/lab. Because if they did, they'd be kicking half of their physicians out of the network and then they wouldn't be making any money themselves.
[B]If the provider has a habit of referring to OON providers/facilties without the notification/approval of the PPO, they will receive a "reminder" letter from the insurance company.[/B]
If you're in an HMO then everything has to be in-network and if your doctor refers you out of it, that should be a violation of his contract and the HMO should discipline him. Which will probably do nothing to help your situation but at least demand they do something about it so it doesn't happen to anyone else, or you again for that matter. It really doesn't sound like that though or they would have told you something along those lines by now--there are PPO plans out there that also only cover in-network services and maybe that's what you have.
[B]If the lab/facility is the ONLY place that performs a diagnostic test, the HMO [U]may[/U] authorize the test at the OON lab.[/B]
Filing an insurance commissioner complaint against your carrier more than likely isn't going to accomplish anything in this situation. They haven't done anything wrong but adhere to the terms of the contract. Like others have pointed out, the buck ultimately stops with you. [U]Almost everyone gets burned like this by a physician's office once before they learn how the system works.[/U] [U]Nowadays you just can't make the assumption that your physician's office has your best financial interests at heart[/U].
[B]:rolleyes: oy vey! That's because his/her primary responsibility is to make sure you receive appropriate treatment for your illness/injury. If a lab test is need to properly diagnose or rule out your illness, and there only one lab that runs that test, then that's where the specimen goes. That's the standard of care. No kickbacks. No conspiracy.
Not obtaining the specimen or running the test, regardless of whether the lab is in network, would be negligent. Then you'd be advising OP to seek legal counsel for malpractice![/B]
Ask pointed questions and [U]if you don't get the answers [B]you want to hear[/B][/U], street them and go to a new one. Good luck.[/QUOTE]
You chose to give horrible advice for your first post! One should "street" the Physician that does not perform a necessary diagnostic test just because it wouldn't be covered by insurance.
The PATIENT (consumer) has the ultimate responsibility for knowing what is and isn't covered by their insurance plan. Claiming ignorance after the fact is not a valid excuse for not paying your bill. In most offices, once the specimen leaves the facility, any billing/insurance/payment issues are between the lab and the patient. There are no kickbacks or fee splitting between the lab and the Physician.
Filing an insurance commissioner complaint against your carrier more than likely isn't going to accomplish anything in this situation. They haven't done anything wrong but adhere to the terms of the contract. [/QUOTE]
They might have adhered to their own contract, but they might not have adhered to state regulations.
In many states, insurance companies and HMOs are legally required to maintain a reasonable level of in-network coverage. One cannot start an HMO with only 2 in-network physicians. Approved HMOs have to file periodic coverage reports and are routinely monitored by state insurance commissions to verify that they provide adequate in-network coverage (e.g., there have to be sufficient specialists of all types, medical providers need to be within certain distance of HMO enrollees, etc..)
It seems that if your HMO network does not include a lab for an essential medical test, the HMO might be violating state regulations. Check with your state insurance commission.
Since we don't know what labs were run, we really don't know if they could have been done at an in-network lab, do we? It seems to me that's just what the doctor told the patient. In fact the only labs that usually run tests that "no other lab can run" are ones that do genetic testing or ones that perform lab work which is in no way, shape, or form a standard of care and are usually billed with miscellaneous CPT Codes. Unless the original poster indicates this was genetic testing, I won't even go into that scenario. Given the relatively low amount of the bill, I doubt it was anyway.
As I said, "reminder" letters are a joke because the PPO networks rarely do anything if the physicians still continue to play the same games. It's an attempt to placate the carrier, it gives the patient the impression that they're at least doing something to correct the behavior, but at the end of the day that's about all that happens for "minor" infractions like this. Minor to the physician and even to the carrier, but major to the patient when they're on the hook for $600.
An HMO may authorize a test at an OON lab--but usually that would require the physician to preauthorize it. Again, no indication the physician made any type of effort to do that. I would also have to guess that the HMO then might even make the physician eat the cost of the labs as a penalty for violating contract. If that's the case then that should be pursued by the patient but it doesn't sound like it.
A patient should absolutely ask a physician pointed questions about what tests they want to run and where the lab work is going to be performed, at an in or out of network lab. If the physician indicates an out of network lab and refuses to accommodate the patient by sending it to an in-net lab, they should absolutely street them. See a physician that will work with them and accommodate their requests--or stay with the original but be prepared to pay out of network costs. Ask them why they want to run said tests and don't be afraid to ask for a second opinion.
Blindly running tests to find out what's wrong without medical justification isn't a standard of care; it's called a shotgun approach and way too many physicians engage in it. Which also drives up the cost of health care. Which also drives up the costs of premiums. Evidence based medicine is the standard of care. This isn't House.
The best advice given so far is to appeal higher in the insurance company. So far there's no proof the insurance did anything wrong and more evidence that the physician is the guilty party here. This isn't some specialist the patient had to see personally. His blood was drawn. It can be shipped to any lab so the odds of the HMO or PPO not having ONE lab that could have performed this testing are slim to none. If this was a test that for some reason couldn't be sent to an in-net lab, then the physician should have been aware of that and preauthorized it with the carrier before the blood was even drawn. The more likely scenario is that the physician--for whatever reason--didn't want to send it to an in-net lab.
While the ultimate responsibility may lay with the patient...would it have been so hard for the physician's office to contact the patient and ask him if it was okay to run the labs out of net? No. Not at all. In fact in any other kind of industry, that kind of forewarning about something that would cost the customer X amount of dollars more would not only be a courtesy, it might make the difference between keeping a customer and losing a customer.
"No kickbacks. No conspiracy". Health care fraud costs billions a year but there's no physician or lab out there that doesn't game the system, huh? Trust me. There are. Not definitely saying this is one of them, but it is a definite possibility. Regardless, now this poster will hopefully know better about the pitfalls of blindly trusting his physician's office to do the right thing. Medicine is a business now, unfortunately. Most run theirs honestly, but enough of them also don't. Graduating from medical school and getting a license isn't the same as being granted sainthood.
[QUOTE=jwmc1701;1922478]. Medicine is a business now, unfortunately. Most run theirs honestly, but enough of them also don't. Graduating from medical school and getting a license isn't the same as being granted sainthood.[/QUOTE]
It's been forced to become a business. One cannot pay their malpractice premiums, medical school loans, mortgage, staff salaries, children's college education, etc., without expecting to be paid for their services. Believe me, we had plenty of years accepting bread, shucked black walnuts, and chicken soup from those unable to pay cash, still do on occasion. Perhaps I remain naive and idealistic, but in more than 20 years in the biz, it's always was, and still is, patient first!
No one asked to be cannonized after graduating medical school, however, there is some expectation of respect for one's education and experience.
If a test is necessary to make a difinitive diagnosis, than it should be ordered, regardless of coverage. Asking for authorization from a representative who has no real medical knowledge and is only reading through questions on a flip card is ridiculous. At times, practicing medicine requires thinking outside the box.
OK, it's early and now I'm cranky. Where's my coffee?
i think the issue needs to be found out if the plan is hmo or ppo, insured medical plan or even a self funded plan. this way we can at least direct the OP where to go. but an appeal is definitely warranted!
[QUOTE=momm2500;1922713]i think the issue needs to be found out if the plan is hmo or ppo, insured medical plan or even a self funded plan. this way we can at least direct the OP where to go. but an appeal is definitely warranted![/QUOTE]
I agree, especially if it truly was the only lab that could perform the test.
Originally, I only wanted to point out that it was out of the Doc's hands once the specimen left the office. The bill is between the lab and patient.
Sorry we got off track.
I think it's pretty obvious that it's an HMO from what's been posted. Most, but not all, HMO plans will allow out of network providers if no in network providers are available, but without actually seeing the policy, we can't know. Assuming everything OP has posted is correct, neither the doctor, nor the lab, nor the insurance company did anything wrong. Sometimes you need a procedure or test done that isn't covered, that's all. Insurance never claims to pay for EVERYTHING and patients often have an unrealistic expectation that anything under the sun should be covered, with no cost to them, just because their doctor says they need it. Unfortunately that's not the way it works, and everyone should read and learn their plans so they don't get surprised when the bill comes.