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  1. #1
    Yasoda is offline Junior Member
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    Unauthorized out of Network lab work

    What is the name of your state? NY

    My doctor who accepts my Health Insurance plan sent my blood samples to a lab that does not accept my health insurance. I was never asked if it was OK to send my blood sample to an out of Network lab. Now the lab is asking me to pay $639.00. My insurance refuses to pay because it says that the lab is not covered by them.
    My doctor says that the best he could do is to write a letter saying that the lab work was needed. How is that going to satisfy the lab? They want payment. It is not right that I should pay for something I never authorized.
    What can I do about this?

    Yasoda
  2. #2
    cbg
    cbg is offline Senior Member
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    Very likely nothing. There is no possible way for your doctor to keep track of what labs are covered on whose insurance. Did you specifically ask the doctor to use a covered lab? It's not his responsibility to determine what labs are in network for YOUR insurance.
  3. #3
    ecmst12 is offline Senior Member
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    Actually if the doctor is in network, then he should actually know what labs work with which insurance companies. That is generally NOT plan specific and applies to the entire company. And it could be part of his contract to send all his samples for those patients to the in-network labs only. So this COULD have been a mistake by the doctor's office. But I don't know if that will obligate the doctor to pay the bill. You can call the lab and see if they are willing to reduce the bill and/or take payments. Meantime tell doc that from now on, you don't want any labs drawn in his office, you will go to the lab yourself to make sure that the tests are being done by the right company.
  4. #4
    cbg
    cbg is offline Senior Member
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    You must work for a company with less complicated network structure than I did. We had labs that were in-network for the PPO plans and out of network for the POS plans, or vice versa, and we won't even go into the HMO plans. The chains were fine; the chains generally either were or were not. But a lot of the independent labs were in for some plans and out for others.
  5. #5
    Yasoda is offline Junior Member
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    I logged in, typed up a reply and when I click on "submit reply" I was told that I'm not logged in. So, I hope this message posted here twice.

    The update:
    My doctor's office knew that the lab does not accept my insurance. They sent it there anyway because no other lab does that kind of blood work. The doctor's office claims that they have done this before and that my insurance paid for it. So, I called my insurance back and told them that the doctor's office had no choice but to send my blood work to this lab because there is no other lab that does this type of work. The insurance company said that it does not matter. They do not pay out-of network bills, period. The insurance company says that I should work things out with my doctor. My doctor says that there is nothing that they could do about it because they are not the ones who sent the bill (the lab did). The doctor's office says that they cannot do anything to help me. The insurance company says the same thing. And now that I'm going to call the lab, guess what they are going to say?

    I feel very angry. I don't want to pay for something that I never asked and never authorized (never authorized to send my blood work to an out of network lab).
    I feel totally helpless and do not know where to turn.
  6. #6
    Yasoda is offline Junior Member
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    I meant to say that I hope this message is "not" posted here twice.
  7. #7
    ecmst12 is offline Senior Member
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    Did you talk to a supervisor at your insurance company? If the out of network lab really was the only place the tests could be sent, then they might have to cover it, but that really depends on your plan's language.
  8. #8
    momm2500 is offline Member
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    Wait! your doctor said that they accepted it before (your insurance company) you should find out when the last time was that you had the same lab work done by the same lab and then question the insurance. hey if they paid it in the past find out why they are not paying it now. also is this a ppo plan or an hmo plan? does your plan say anything in it that prevents not in network services are not covered? most (not all) do consider out of network providers but the benefits are different. usually going towards a deductible or something
  9. #9
    Yasoda is offline Junior Member
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    Good idea about asking the doctor's office when it was the last time that my insurance paid out of network lab work. I hope this office is willing to give me that information. They seem that they don't really want to deal with this and have me fight it out with the insurance.
    I will call my insurance to see if I'm ppo or HMO. I have been so ignorant about these things. All I have been doing these years is go to a network provider and that was that.
    I do know that I don't have to get authorization from my primary doctor to go to other doctors and specialists.
    The insurance company did say that they only pay medical and lab bills from in network providers. They told me that my insurance company does not pay for out of network, regardless of the situation (that would include a lab that is the only lab that does this type of work). They also added that if I were to appeal it, I would certainly loose because they are very strict about not paying out of network providers.
    So far, the insurance company dug their heels and they say they won't go against their contract. Meanwhile, the doctor's office does not want to help me with this case because they said they did the only thing they could (sending my blood sample to the only lab that would do that work) and it is up to me to straighten out the money issue.
    Does anybody think that I'll have a chance if I appeal?
  10. #10
    achiles is offline Junior Member
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    Yes, you should appeal in writing. You have nothing to lose. Even if the appeal is denied, you will at least have the reason for the denial in writing. You can then use that to file a complaint against the insurance company with the state insurance commissioner.
  11. #11
    Yasoda is offline Junior Member
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    I feel so angry about this. The insurance company says that this matter is about myself, the doctor and the lab and I should work it out with them. The doctor's office says that this matter is out of their hands and I should work it out with the lab and the insurance company. Today I called the lab and they said that they did the work and I should work it out between my insurance and the doctor. Meanwhile the insurance company is saying if the bill is not paid on time they are sending me to a collection agency.
    It seems that no one seems to care that I never knew that my blood was sent to a lab that was out of network.
    It doesn't seem fair, I went to a doctor that accepts my insurance and now I have to pay $639.00 because my blood work was sent to an out of network lab.

    Does anyone know if there a "patients rights" advocacy group somewhere.

    Yasoda
  12. #12
    ecmst12 is offline Senior Member
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    You are looking at this wrong. Your blood work was sent to an OON lab because it HAD to be. Your health plan is an HMO that does not pay out of network benefits no matter what. This is a test that you needed to have done, so you should pay for it. Next time open enrollment comes up, you can see if there are any other options besides this plan that you can choose.
  13. #13
    jwmc1701 is offline Junior Member
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    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.

    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.

    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 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.

    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. 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.
  14. #14
    moburkes is offline Senior Member
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    Quote Originally Posted by jwmc1701 View Post
    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.
    The post said that this is the ONLY lab that does this type of bloodwork.
    My new signature:
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  15. #15
    momm2500 is offline Member
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    out of network

    i do not see how this is a scam. with comments like that gives everyone the incorrect information that is not needed. first if the lab is quest or lab corp; they mostly particpate with all ppo's and hmo's. if it is a different lab they might not. when you write your appeal to the insurance company, it would be wise to get the doctor's office to include some type of note indicating that this is the only lab that does this service. (i find that highly unlikely that it is the only lab) every bit of information you can plead your case does help. talk directly to the doctor not the office girls; talk to a supervisor at the insurance company not just the customer service people. go higher in your quest but you should appeal in writing immediately.

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