Would you pay? (RE: Blood test claim rejected by insurance as experimental)

[Pegasus]

A doctor ran a series of blood tests and my health insurance rejected the claim for about half of them, claiming they were experimental.  I brought the EOB back to the doctor during a follow up and he was incensed, insisting that the tests were "standard of care" for my condition and that he would have left himself open to a malpractice lawsuit if he didn't order them.  He had his office look into the insurance claim and it was resubmitted.  Rejected again, same reason.

 

Now the lab has sent the bill to me.  Understandable.  But here is what irks me:

 

For the blood tests the insurance covered, the lab billed $646 and the insurance paid $104; about 16% of the billed amount.  The lab accepted this as full payment for those tests.

 

For the blood tests the insurance rejected, the lab billed $865.  I called to request a self-pay discount  and they refused. This lab is known for not discounting the billed amount for individuals and, in fact, there are class action lawsuits against the lab for overcharging cash-paying clients.

 

I can afford to pay this bill but I am so annoyed I'm tempted to just not.  Eventually, the lab will sell the account to a collection agency for pennies on the dollar and my credit score will be impacted.  I have a great credit score and no intention of seeking a loan within the next few years.  

 

Wanted some feedback on what others would do in this situation. I admit that when I'm annoyed I don't always act rationally.  :cursing: 

 

 

[Jean in Newcastle]

Your insurance company should have an appeal process for claims that is separate from just resubmitting. In my experience if it is resubmitted they just see if it was processed before (without looking at the details) and then reject it as a double claim. I would go through the official repeal process.

 

 

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[LucyStoner]

I would pay but not until I filed an appeal with my insurance company. You are legally entitled to appeal their decision, they have to have a process for you to do so but they generally will not tell you that. The customer service reps

at the insurance company can't help you. Insist on speaking to their appeals department and then outline your situation in writing.

[prairiewindmomma]

Now go through the appeal process for the insurance company.  Sometimes they will pay, unless they have an explicit statement on such tests.  BTDT, I've got about a 50% success rate.

[SparklyUnicorn]

I would appeal.

 

[J-rap]

I'd be furious too.  Can you get your doctor to call the insurance company?  Once or twice, we did that and the amount due was changed.

[SparklyUnicorn]

The denial could be flat out a mistake.  I had two claims denied fairly recently because they said I maxed out my benefit for the service.  This was for conjunctivitis.  It made absolutely no sense, but the rep on the phone just parrots back what it says on the claim.  So I appealed.  It took them FOREVER and I called them several times and bugged them.  FINALLY they paid the dang claims.  It probably was a mistake somewhere along the way.

 

 

[3 ladybugs]

Can you look at other labs and see if they see them as experimental? If other labs don't see them as that, then you would have really good grounds for appeal. I would also call your insurance company and ask them specifically what they consider the "standard of care" is for your condition. What tests specifically do they think is standard of care. Use the phrase "Standard of Care" because it should scare them a bit because if your doctor was right, they should have paid. 

[shawthorne44]

I wouldn't pay.  

[Jean in Newcastle]

I would not just refuse to pay.  It will be sent to collections if you do.  It will affect your credit rating negatively.  You have a process (the appeal) that has not been done  yet.  Once the appeal is started, let the lab know to put their invoice on hold until the results are known so that it isn't sent to collections anyway. 

[Spryte]

Appeal.

 

Then I’d pay.

 

FWIW, we had so many uncovered medical bills we had to get a home equity line of credit. No stranger that uncovered bills here. It stinks. We are still paying off the treatment that saved my life and made me mobile again.

[prairiewindmomma]

I forgot to add one last tidbit, if you lose the appeal, ask that the lab re-bill that portion with what would've been their insurance write-off.  Sometimes it works.   

[ktgrok]

 

 

 

 

After two hours of ridiculousness, I reported the insurance company to the state insurance regulatory board,  and I told each and every insurace rep I talked to on the phone that day that I had opened a complaint. That really did help escalate it. 

 

Yup. I've been fighting to get my insurance to pay my midwife for 9 months now. Mind you, I have a signed letter from them from before I had the baby saying they agreed to pay her as in network,and yet here we are, fighting again. I finally spent a LONG time on the phone with them, then filed a complaint with the state insurance board. Sure enough, they paid her yesterday! And I've heard from others that filing a complaint fixes things. My state has it so you can file a complaint online!

[laundrycrisis]

Always appeal, at least twice. I believe they

deny things that should never be denied because they know most people won't challenge the denials and it's easy savings for them.

Edited January 5, 2018 by laundrycrisis

[Word Nerd]

Appeal it in writing along with any documentation that supports your case.

[ktgrok]

Always appeal, at least twice. I believe they

deny things that should never be denied because they know most people won't challenge the denials and it's easy savings for them.

The insurance company basically admitted that to me

[QueenCat]

If I lost the appeal, I'd pay. Every job dh applies for requires a credit report check. He also has to keep his security clearance. They don't like dings like that on your credit reports, which are definitely a part of security clearances.

[ktgrok]

As for them purposely not paying to see if you appeal...yes. I got a pre-authorization for in network coverage of my midwife. Signed letter outlining how they would pay. They still paid it as out of pocket. I called twice, and they still paid it out of pocket. I finally escalated and refused to get off the phone, and filed a complaint with the insurance commissioner, and was told, by the person at the insurance company, that even with a pre-auth for in network coverage they AUTOMATICALLY still pay the out of network rate until and unless you appeal it!!!! Total scam.

[Kassia]

Well, I'd appeal. And that's right where we now. Miraculously, our insurance has declared that my dh does NOT have Stage IV melanoma, thus not needing the test to determine which kind! It's a Christmas miracle--not!

 

:grouphug:  :grouphug:   I can't imagine having that additional stress.  I'm sorry.