lealea1005
Senior Member
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.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.
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
Almost all PPO contracts have a clause which states that a physician is supposed to use every effort to use another in-network physician, facility, lab, etc. 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.
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.
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.
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.
If the lab/facility is the ONLY place that performs a diagnostic test, the HMO may authorize the test at the OON lab.
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. Almost everyone gets burned like this by a physician's office once before they learn how the system works. Nowadays you just can't make the assumption that your physician's office has your best financial interests at heart.
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!
Ask pointed questions and if you don't get the answers you want to hear, street them and go to a new one. Good luck.
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.
Last edited: