Medical Claim Denied and Appeal Denied

[jeromedawg]

Hey all,

I saw a Rheumatologist earlier this year who had me do some lab work related to genetic testing. The claim was denied by my insurance company as they indicated it was "investigational" which isn't something they cover. I had my doctor write a letter to appeal the denial and just received the response from my insurance company, indicating that the appeal was denied still due to the fact that there was still insufficient reasoning in why this lab was ordered. The basis is that this lab work was ordered as "investigational" which is not covered apparently.

The condition he was testing for indicators of is known as "Hemachromatosis" of which one indicator is elevated iron counts. One of the points which they used as leverage to deny the claim was that the record my doctor sent did not inform of an abnormal amount of iron in the blood (I'm checking if I do have lab results that indicate this though).

They're also saying this is the final decision for them and if I don't like it I can basically go complain elsewhere.

Have any of you dealt with your insurance on a similar issue where they wouldn't cover a procedure/lab/etc due to it not being "medically necessary" or gone through something like this? The lab work is gonna end up cost like $530~ or so. At this point, I'll probably end up just paying it. Such a PITA though...

[I'm a red panda]

Your state should have an insurance board you can appeal the claim to if you think your appeal was wrongly denied.

[jeromedawg]

Your state should have an insurance board you can appeal the claim to if you think your appeal was wrongly denied.

Thanks. The other thing I was wondering about is if I should pay the bill for lab work, which I've received several invoices for. I'm kinda thinking that's probably the safer thing to do no? Then if I decide to appeal further, and end up winning, is the insurance company supposed to cut a check back or what not?

[The_Dude]

Your state should have an insurance board you can appeal the claim to if you think your appeal was wrongly denied.

Thanks. The other thing I was wondering about is if I should pay the bill for lab work, which I've received several invoices for. I'm kinda thinking that's probably the safer thing to do no? Then if I decide to appeal further, and end up winning, is the insurance company supposed to cut a check back or what not?

I don't have experience with disputing claims with an insurance company but yes this is generally the best method when dealing with large established companies.  Otherwise, you are liable to have the insurance company add penalties and even send you to collections.

[Dee18]

You could try to negotiate with the lab to pay whatever the insurance company would have paid had it been covered.

[jeromedawg]

You could try to negotiate with the lab to pay whatever the insurance company would have paid had it been covered.

Good idea -that would save a lot more time. But how exactly do you "negotiate"? Do I go into detail about how insurance denied the claim and that I've been spending a lot of time just trying to appeal with no success? Or is that too much? What should I say?

[Abe]

Hi, I've dealt with a lot of these for my patients.

I'd call the lab company and literally tell them that the insurance company denied the claim, is there a lower rate they can provide you? Most companies will work with you on this, especially if their lab is not a standard test for whatever disease they're marketing it for. Their idea is if enough patients get their test, they'll accumulate enough data for it to be standard of care. They'll have some form to fill out and you'll need to fax over the denial. Sometimes they'll argue with the insurance company but usually they don't. This has been the most successful path for our patients, and some of these tests have ended up being covered by insurance once they had enough data to support the cost.

The insurance company will probably not cover the testing if it's not standard for diagnosis of hemochromatosis. Your physician should have checked with the company beforehand. It's unclear if they would still deny it with supporting lab work; it doesn't hurt (except in time) to try again with the lab work they want. Still highly likely they'll deny it if it's investigational.

Good luck! Try the lab company first, that's your best bet.

[Freedomin5]

And just an FYI for next time if you ever require any procedure that’s outside of your normal “visit your GP for [reason]”, always always always contact your insurance first and ask for a Guarantee of Payment (also known as Pre-Authorization). Basically your insurance reviews the medical record first and gives you a formal letter indicating that they will cover X procedure on [date] for $[amount]. Then at least you will know before hand whether or not that’s particular procedure is covered, and if it’s not, you can discuss other options with your doctor.

[Askel]

Yes, I've successfully appealed a denied claim before.  It ultimately landed before the local judge and required legal representation.

If I could avoid that whole nightmare by just writing a check for $530, I would have done so in a heartbeat. 

[pecunia]

Sure seems that medicine would be a lot simpler if we just jettisoned the insurance companies and paid into a pool through our taxes.  They may still not pay for everything, but you would know because it would be the same for everyone.  I think this medicine thing is a rising issue in the United States.

[SimpleCycle]

If your provider did indeed order a Hemochromatosis genetic test without an elevated iron level, I would not expect the insurance company to approve the claim or appeal.  But I would first see if it's just that the office didn't send the required documentation to get the test approved.  Frankly, I'd be angry at the rheumatologist's office for this, not the insurance company.

[Psychstache]

Been there, done that, got the T-shirt. Claim denied, and multiple appeals denied despite letters from physician and metric shit-tonnes of documentation. I gave up and paid up. Silver lining, it was an itemizing year and was was already over the 10% threshold, so I like to think I got a small discount.

[jeromedawg]

If your provider did indeed order a Hemochromatosis genetic test without an elevated iron level, I would not expect the insurance company to approve the claim or appeal.  But I would first see if it's just that the office didn't send the required documentation to get the test approved.  Frankly, I'd be angry at the rheumatologist's office for this, not the insurance company.

I'm not upset at the insurance company at all - I'm really not happy with the doctor as you say I should be. His responses have been slightly defensive but also "I could care less."
I don't think they sent anything over prior, as they are awful in terms of administration. I saw this doctor for a second opinion and this is what I get... he seems nice, warm and caring but his wife/front office is terrible and they even skimped on printing and copying. They were hesitant to print/copy anything and then reused paper that had been printed on (just flipped it over) with the lightest ink setting possible (that or they were running the cartridges dry). His wife/admin also didn't know what an "invoice" is so printed out the procedures done and had the doctor write explanations... ?!? So bizzare. Its as if they don't have an actual invoicing system. I couldn't believe it but now that I think about it, it doesn't surprise me. The first rheumatologist I saw actually made the effort to check or have his staff check on various medicines/prescriptions for coverage. I realize that might be a bit different than ordering a lab, but still. Who/Where can and/or should I complain to regarding this doctor? I'm probably going to go on Yelp lol and maybe my insurance provider's portal and see if I can leave him a poor review.

Anyway, learned my lesson and will always ask for a "Guarantee of Payment" per Freedomin5.

[SimpleCycle]

@jeromedawg, that sounds like a mess!  Unfortunately it sounds like this doc is in private practice, so you are pretty limited in who you can complain to.  Ugh, I'm mad on your behalf!

[ETBen]

Here’s my advice having worked on both sides.

1.  Call the lab and ask for a 3 month hold until you work it out with the insurance. They usually will do this.

2. Call the insurance member advocate and confirm exactly what coding and clinical information meets the needs for this to be approved.

3.  Confirm the physician billed those exact codes and provided that exact record.

4.  Insurers often have open loops and it doesn’t get properly reviewed on the appeal. So check that too. Even when the clinical data is provided, they may still be looking for a specific code too.

5.  State insurance board.

6.  Then if not resolved work out anpayme t plan.

7.  Yes the system is impossible to navigate and stupid. Even when it is designed well.

[ETBen]

Oh and based on your experience with the wife. There is a big chance they aren’t submitting info in a way that is reviewed by the insurer. It doesn’t matter if it is correct if they arent submitting it the right way. I’ve had this argument the most with small practices. So if the provider is the issue, your state medical board is a resource.

[jeromedawg]

Here’s my advice having worked on both sides.

1.  Call the lab and ask for a 3 month hold until you work it out with the insurance. They usually will do this.

2. Call the insurance member advocate and confirm exactly what coding and clinical information meets the needs for this to be approved.

3.  Confirm the physician billed those exact codes and provided that exact record.

4.  Insurers often have open loops and it doesn’t get properly reviewed on the appeal. So check that too. Even when the clinical data is provided, they may still be looking for a specific code too.

5.  State insurance board.

6.  Then if not resolved work out anpayme t plan.

7.  Yes the system is impossible to navigate and stupid. Even when it is designed well.

I'm thinking even pre-1 or 1a: "call the lab and ask for the contracted rate" right? I'd rather avoid all that other hassle if it means they can just give me the contracted rate and put all this past, as annoying as it is.

[jeromedawg]

Hi, I've dealt with a lot of these for my patients.

I'd call the lab company and literally tell them that the insurance company denied the claim, is there a lower rate they can provide you? Most companies will work with you on this, especially if their lab is not a standard test for whatever disease they're marketing it for. Their idea is if enough patients get their test, they'll accumulate enough data for it to be standard of care. They'll have some form to fill out and you'll need to fax over the denial. Sometimes they'll argue with the insurance company but usually they don't. This has been the most successful path for our patients, and some of these tests have ended up being covered by insurance once they had enough data to support the cost.

The insurance company will probably not cover the testing if it's not standard for diagnosis of hemochromatosis. Your physician should have checked with the company beforehand. It's unclear if they would still deny it with supporting lab work; it doesn't hurt (except in time) to try again with the lab work they want. Still highly likely they'll deny it if it's investigational.

Good luck! Try the lab company first, that's your best bet.

Thanks! I called Quest but they didn't offer any sort of up-front discount/rate change. They did say what I could do is submit a "financial assistance" request which it sounds like could be what you're alluding to? Anyway, I guess I'll fill the form out and send it in, although it seems like they base any decision for discount on your current financial status in conjunction with the claim denial. Who knows though...

So the doctor ordered a "hemochromatosis gene analysis" which is at least one if not the only item that wasn't covered at all. As far as supporting lab work, I'm not sure what else is needed - I don't know if my prior labs contain an "iron count" or what that would show up as. The only things the doctor outlined were elevated hemoglobin and hematocrit counts from prior other labs I had done. I think he had iron testing done in the same lab work where he ordered the hemochromatosis analysis. I'm not happy with this doctor though because it doesn't seem like he has any other "supporting evidence" -- either that or he's not wanting to provide it for whatever reason. Or maybe he realizes he screwed up as he was "just guessing" and doesn't want to have any more to do with it.

[mm1970]

Here’s my advice having worked on both sides.

1.  Call the lab and ask for a 3 month hold until you work it out with the insurance. They usually will do this.

2. Call the insurance member advocate and confirm exactly what coding and clinical information meets the needs for this to be approved.

3.  Confirm the physician billed those exact codes and provided that exact record.

4.  Insurers often have open loops and it doesn’t get properly reviewed on the appeal. So check that too. Even when the clinical data is provided, they may still be looking for a specific code too.

5.  State insurance board.

6.  Then if not resolved work out anpayme t plan.

7.  Yes the system is impossible to navigate and stupid. Even when it is designed well.

I'm thinking even pre-1 or 1a: "call the lab and ask for the contracted rate" right? I'd rather avoid all that other hassle if it means they can just give me the contracted rate and put all this past, as annoying as it is.

ETBen has good advice.

A decade and a half ago, we were sent to collections for an unpaid doctor bill.  Regular annual checkup.  Maybe $100-200?  What happened?

It got lost in the middle man.  You see, the doctor's office sends the bill to the "middle man", that does the accounting and re-pricing, and they send it on to the insurance company.

We get the bill a year and a half later, and start making calls.  At this point, we've changed insurance even.

In the end, after 2 months, the ONLY way we got it worked out was: my husband got the number for the middle man.  He got the bill with all the info from the doctor.  He faxed it to the middle man.  He called the middle man to make sure they got it.  They then sent it on to the insurance company.  Ridiculous.  Why not just pay?  It's the fucking principle and we're engineers.


Experience #2:
Kid 2 needed surgery at 9 months.  We had to first get a referral from the pediatrician to the specialist.  It was a surgery that the specialist no longer performed, so he referred us to UCLA.  We submitted our info to the insurance company and got the pre-authorization code and everything.

Then we scheduled the surgery.  By the time the surgery happened, the pre-auth code had expired.  The first thing we get is a bill from UCLA.  The next thing we get is a letter from my insurance company (my kids were double covered at that point, and mine was the primary) saying that "we are denying all payment because this was not an emergency surgery".  Well, duh, hence the pre-auth.  Many phone calls later, husband's insurance pays their share (the co-ins part, 20% I think?  It was a $20-25k surgery.)  Here I am in open enrollment in October, the surgery was in April.  No changes this year and LOOK - "outpatient surgery - cost to the patient $125."

Another phone call to UCLA about that "oh, you are right!  $125 it is on your plan.  You can pay us and we'll deal with the insurance."  Paid the $125 out of husband's HSA.  After all that we learned the following: the proper course of action in this particular case is that UCLA had to bill my home doctor's group, and the home doctor's group needed to forward it to the insurance.  It couldn't come directly from UCLA because of strange HMO rules.

Got all that settled but then we got the doctor's bill.  Sigh.  At least we knew how to deal with it then, but the last bill got paid 18 MONTHS after the surgery.

[jeromedawg]

Also, this "Patient Financial Assistance Program" via Quest requires the following items:

A copy of last year’s W2 form
A copy of last year’s income tax return
A copy of your most recent pay stub (s)
A proof source indicating that you are eligible for local, state, or federal
assistance programs.

So it doesn't sound like it's for 'data aggregation' per se.

[jeromedawg]

So it sounds like what the doctor *should* have done to avoid all this was to have my iron levels tested *first* and then order a separate lab for the hemochromatosis in the case that the iron levels were elevated. Instead, he played a 'guessing game' based on other factors that "pointed to" elevated iron levels (elevated hemoglobin and hematocrit) but were not actually determinative of it compared to actually testing for iron itself.

[jeromedawg]

Here’s my advice having worked on both sides.

1.  Call the lab and ask for a 3 month hold until you work it out with the insurance. They usually will do this.

2. Call the insurance member advocate and confirm exactly what coding and clinical information meets the needs for this to be approved.

3.  Confirm the physician billed those exact codes and provided that exact record.

4.  Insurers often have open loops and it doesn’t get properly reviewed on the appeal. So check that too. Even when the clinical data is provided, they may still be looking for a specific code too.

5.  State insurance board.

6.  Then if not resolved work out anpayme t plan.

7.  Yes the system is impossible to navigate and stupid. Even when it is designed well.

Okay, so I contacted insurance to inquire about #2. Basically what they told me is the doctor used the diagnostic code for "joint pain" as the code to correspond with the hemochromatosis genetic analysis lab order. Since the diagnostic code is not classified as "genetic" it was immediately denied. He would have to resubmit the diagnostic code as one being associated as "genetic" and provide supplemental detail/evidence supporting his request for this lab in order for it to potentially be approved. She referred me to https://www.anthem.com/medicalpolicies/policies/mp_pw_c178373.htm

At this point, I'm not sure if this is enough to determine that the doctor basically was just "shooting in the dark" (thus eliminating the need for #3, also because I'm not happy with this doctor at the moment and don't want to talk to him as frustrating as it has been).

I wasn't sure what exactly to ask about per #4 in light of all that I've been told by Anthem up to this point. It sounds like, from what I was told, that he would need to resubmit with a different diagnostic code and then provide supporting information. But the whole premise of him running this was all based on "joint pain" which I find odd - you would think he would know better than to do that if it meant incurring costs outside of scope. But he obviously doesn't care per my current communications with him thus far.

Is the State Insurance board the same as "California Consumer Assistance Program Operated by the CA Dept of Managed Health Care and Dept of Insurance" then? And if I write them am I complaining about the doctor and his practice and trying to get them to hold him accountable to all this mess?

One other thing I don't know that I specifically mentioned too is that I still have the opportunity to request an external review by 3rd party through Anthem. Wondering if I should exhaust this option too.

[Altons Bobs]

Is your insurance plan an Individual plan or a Large Group plan or something else?

[jeromedawg]

Is your insurance plan an Individual plan or a Large Group plan or something else?

It's an HSA based plan w/ high deductible. PPO so I can choose whichever provider versus HMO, etc

[Paul der Krake]

So not through employer? My megacorp has a bunch of people on staff I can go to who will try to get these types of issues resolved on behalf of employees (the rationale being that employees then won't spend their days arguing on the phone themselves).

[jeromedawg]

So not through employer? My megacorp has a bunch of people on staff I can go to who will try to get these types of issues resolved on behalf of employees (the rationale being that employees then won't spend their days arguing on the phone themselves).

Oh it is through my employer. I never thought of that - I'll give my company a call to see if they will do anything. I haven't heard of anything like this before but it makes sense.


EDIT: just called and, unfortunately, they don't offer any sort of advocate/ombudsman service to resolve these kinds of things. Sucks knowing that the service exists yet my company (large bank) doesn't offer it.

[I'm a red panda]

So not through employer? My megacorp has a bunch of people on staff I can go to who will try to get these types of issues resolved on behalf of employees (the rationale being that employees then won't spend their days arguing on the phone themselves).

Wow, that's awesome. We definitely don't have that.  Though I'm at meganonprofit not corp.
I had a $12,500 charge denied, and my appeal was unsuccessful. For weird reasons, I couldn't appeal to my state. After about 30 hours of work, I gave up.  It was too much emotional stress to keep dealing with it at that point in my life.

[jeromedawg]

So not through employer? My megacorp has a bunch of people on staff I can go to who will try to get these types of issues resolved on behalf of employees (the rationale being that employees then won't spend their days arguing on the phone themselves).

Wow, that's awesome. We definitely don't have that.  Though I'm at meganonprofit not corp.
I had a $12,500 charge denied, and my appeal was unsuccessful. For weird reasons, I couldn't appeal to my state. After about 30 hours of work, I gave up.  It was too much emotional stress to keep dealing with it at that point in my life.

!!@#)*@&(*!@#!!!  that's awful! Did you have any other recourse against the provider at least?

[Car Jack]

2nd level appeal.  I've done it and won.  Technically, I should have lost.  With a cardiac history, I showed up in the e room with chest pain.  Hospital in plan.  ER doc not.  In my 2nd appeal, I included the quote "So next time I'm in an emergency room with chest pain, should I tell the doctor not to work on me since he's not in plan and hope that the doctor on the next shift is in plan, or till I just die".

[I'm a red panda]

So not through employer? My megacorp has a bunch of people on staff I can go to who will try to get these types of issues resolved on behalf of employees (the rationale being that employees then won't spend their days arguing on the phone themselves).

Wow, that's awesome. We definitely don't have that.  Though I'm at meganonprofit not corp.
I had a $12,500 charge denied, and my appeal was unsuccessful. For weird reasons, I couldn't appeal to my state. After about 30 hours of work, I gave up.  It was too much emotional stress to keep dealing with it at that point in my life.

!!@#)*@&(*!@#!!!  that's awful! Did you have any other recourse against the provider at least?

No, the provider bill fairly, and I was aware of the charge when I had the procedure.

I actually THOUGHT my insurance wouldn't cover it, and was shocked when I saw they did- but they did some complete bullshit when they decided on allowable charges (basically equated it to a procedure I didn't have), they should have covered about $11k of it, and they covered less than $1k.

[I'm a red panda]

2nd level appeal.  I've done it and won.  Technically, I should have lost.  With a cardiac history, I showed up in the e room with chest pain.  Hospital in plan.  ER doc not.  In my 2nd appeal, I included the quote "So next time I'm in an emergency room with chest pain, should I tell the doctor not to work on me since he's not in plan and hope that the doctor on the next shift is in plan, or till I just die".

Glad you won it :)

[Askel]

After about 30 hours of work, I gave up.  It was too much emotional stress to keep dealing with it at that point in my life.

After having been through this, I'm pretty sure this is the official strategy of insurance companies. 

Every appeal we made was just met with a completely bizarro rebuttal from the insurance company full of mistakes and just plain wrong information.  Like they knew they were wrong, but were just going through the motions so they didn't have to admit it. 

Every rebuttal involved another couple days of work debunking their arguments and pointing out the mistakes.  Thankfully my wife is stubborn as hell and was fighting for a lot of people who also had their brace denied, otherwise I just would have paid the bill very early in the process. 

It's only because we had an immense amount of help from friends and family in the legal and medical industries that this was actually a profitable endeavor in the end. (At least in dollars, probably not in time.) 

[Paul der Krake]

After about 30 hours of work, I gave up.  It was too much emotional stress to keep dealing with it at that point in my life.

After having been through this, I'm pretty sure this is the official strategy of insurance companies. 

Every appeal we made was just met with a completely bizarro rebuttal from the insurance company full of mistakes and just plain wrong information.  Like they knew they were wrong, but were just going through the motions so they didn't have to admit it. 

Every rebuttal involved another couple days of work debunking their arguments and pointing out the mistakes.  Thankfully my wife is stubborn as hell and was fighting for a lot of people who also had their brace denied, otherwise I just would have paid the bill very early in the process. 

It's only because we had an immense amount of help from friends and family in the legal and medical industries that this was actually a profitable endeavor in the end. (At least in dollars, probably not in time.)

I have a suspicion that employees of large employers who self-insure (i.e. they only use the insurance company for administrative services and bear claim responsibility themselves) have an easier time, because the insurance company gets paid no matter what. I can't prove it, but maybe someone has done the analysis?

[Altons Bobs]

So not through employer? My megacorp has a bunch of people on staff I can go to who will try to get these types of issues resolved on behalf of employees (the rationale being that employees then won't spend their days arguing on the phone themselves).

Oh it is through my employer. I never thought of that - I'll give my company a call to see if they will do anything. I haven't heard of anything like this before but it makes sense.


EDIT: just called and, unfortunately, they don't offer any sort of advocate/ombudsman service to resolve these kinds of things. Sucks knowing that the service exists yet my company (large bank) doesn't offer it.

If it's a self-funded plan, that means your employer is the claim payer, the insurance company just processes the claims according to what your employer wants them to do, but your employer decides what they want to pay and what they don't. If it's a self-funded plan, I'd say to talk to HR and convince them to pay it for you. The insurance company only pays claims higher than the stop loss amount, which is normally a lot higher than what you mentioned, so if it's a self-funded plan, your employer is actually the one paying the claims.

[jeromedawg]

So not through employer? My megacorp has a bunch of people on staff I can go to who will try to get these types of issues resolved on behalf of employees (the rationale being that employees then won't spend their days arguing on the phone themselves).

Oh it is through my employer. I never thought of that - I'll give my company a call to see if they will do anything. I haven't heard of anything like this before but it makes sense.


EDIT: just called and, unfortunately, they don't offer any sort of advocate/ombudsman service to resolve these kinds of things. Sucks knowing that the service exists yet my company (large bank) doesn't offer it.

If it's a self-funded plan, that means your employer is the claim payer, the insurance company just processes the claims according to what your employer wants them to do, but your employer decides what they want to pay and what they don't. If it's a self-funded plan, I'd say to talk to HR and convince them to pay it for you. The insurance company only pays claims higher than the stop loss amount, which is normally a lot higher than what you mentioned, so if it's a self-funded plan, your employer is actually the one paying the claims.

As far as whether it's self-funded or not I don't know - all I know is that I pay a monthly cost for the insurance and my deductible ends up being higher. I contribute to an HSA but I'm still paying that monthly fee for the insurance itself. So in that sense, I'm not entirely certain it would be considered "self-funded" if we were to define it in that context.

Per my last response, it seemed like the response from my company was more or less "SOL for you" - I'm not sure what else I can possibly say to convince them to pay the claim. It would have to be something quite exceptional for that to happen I'm guessing...

[ETBen]

Here’s my advice having worked on both sides.

1.  Call the lab and ask for a 3 month hold until you work it out with the insurance. They usually will do this.

2. Call the insurance member advocate and confirm exactly what coding and clinical information meets the needs for this to be approved.

3.  Confirm the physician billed those exact codes and provided that exact record.

4.  Insurers often have open loops and it doesn’t get properly reviewed on the appeal. So check that too. Even when the clinical data is provided, they may still be looking for a specific code too.

5.  State insurance board.

6.  Then if not resolved work out anpayme t plan.

7.  Yes the system is impossible to navigate and stupid. Even when it is designed well.

Okay, so I contacted insurance to inquire about #2. Basically what they told me is the doctor used the diagnostic code for "joint pain" as the code to correspond with the hemochromatosis genetic analysis lab order. Since the diagnostic code is not classified as "genetic" it was immediately denied. He would have to resubmit the diagnostic code as one being associated as "genetic" and provide supplemental detail/evidence supporting his request for this lab in order for it to potentially be approved. She referred me to https://www.anthem.com/medicalpolicies/policies/mp_pw_c178373.htm

At this point, I'm not sure if this is enough to determine that the doctor basically was just "shooting in the dark" (thus eliminating the need for #3, also because I'm not happy with this doctor at the moment and don't want to talk to him as frustrating as it has

So here’s the deal. It’s not about whether he should have ordered the test. What she’s tell you is that the lab isn’t paid without a correct supporting code. The provider didn’t submit the right code. Think of claims processing as If/Then statements.

If you can’t get him to resubmit with a correct code (either bc he doesn’t know it or he won’t do it), file a second level appeal and reach out to a medical advisor with the insurance company. Be clear that the provider refuses to submit the correct claim. This situation is really common with small offices who don’t use billing and coding companies who stay up to date. Most of these claims are denied not bc they arent medically necessary or indicated. Its because the providers don’t know how to submit the initial claim for it. Insurers also change it so often that they can’t keep up.

MInsurers have a duty to ensure their contracted providers submit accurate claims and that as a member your claims are processed correctly. But you need to word it the right way to get attention.  I can say with 99% certainty that you should not be paying for this. And ask Quest to put a hold on the account while the claims are reprocessed. I have done this before as a patient. There is no situation here where you should be paying for this. Patients need to know their benefits, but this would be beyond that scope of expectations.

[Abe]

Agree with above. Here's what happened: When we order lab tests, each one has to have a specific diagnosis associated with it. It seems that in this case he used a generic diagnosis like "joint pain" (which is really a symptom, but that's a whole different rabbit-hole to go down) and not having something more specific (or even putting "hemochromatosis" if that's what they think you have). It's one of those "got ya" things that insurance companies do.

Here's how I would try to fix it: If you can get the physician to fix the diagnosis code, and fax their note along with your labs (including an iron panel, your CBC and your liver function tests), then the insurance company may process it. If they aren't even willing to try, then write a letter of complaint to their boss saying "my doctor ordered a very expensive lab test, the insurance company denied the claim because it was incorrectly billed, and the doctor is not willing to help me fix the billing problem."

I'm sorry this has been such a ridiculous wild goose chase.

[jeromedawg]

Here’s my advice having worked on both sides.

1.  Call the lab and ask for a 3 month hold until you work it out with the insurance. They usually will do this.

2. Call the insurance member advocate and confirm exactly what coding and clinical information meets the needs for this to be approved.

3.  Confirm the physician billed those exact codes and provided that exact record.

4.  Insurers often have open loops and it doesn’t get properly reviewed on the appeal. So check that too. Even when the clinical data is provided, they may still be looking for a specific code too.

5.  State insurance board.

6.  Then if not resolved work out anpayme t plan.

7.  Yes the system is impossible to navigate and stupid. Even when it is designed well.

Okay, so I contacted insurance to inquire about #2. Basically what they told me is the doctor used the diagnostic code for "joint pain" as the code to correspond with the hemochromatosis genetic analysis lab order. Since the diagnostic code is not classified as "genetic" it was immediately denied. He would have to resubmit the diagnostic code as one being associated as "genetic" and provide supplemental detail/evidence supporting his request for this lab in order for it to potentially be approved. She referred me to https://www.anthem.com/medicalpolicies/policies/mp_pw_c178373.htm

At this point, I'm not sure if this is enough to determine that the doctor basically was just "shooting in the dark" (thus eliminating the need for #3, also because I'm not happy with this doctor at the moment and don't want to talk to him as frustrating as it has

So here’s the deal. It’s not about whether he should have ordered the test. What she’s tell you is that the lab isn’t paid without a correct supporting code. The provider didn’t submit the right code. Think of claims processing as If/Then statements.

If you can’t get him to resubmit with a correct code (either bc he doesn’t know it or he won’t do it), file a second level appeal and reach out to a medical advisor with the insurance company. Be clear that the provider refuses to submit the correct claim. This situation is really common with small offices who don’t use billing and coding companies who stay up to date. Most of these claims are denied not bc they arent medically necessary or indicated. Its because the providers don’t know how to submit the initial claim for it. Insurers also change it so often that they can’t keep up.

MInsurers have a duty to ensure their contracted providers submit accurate claims and that as a member your claims are processed correctly. But you need to word it the right way to get attention.  I can say with 99% certainty that you should not be paying for this. And ask Quest to put a hold on the account while the claims are reprocessed. I have done this before as a patient. There is no situation here where you should be paying for this. Patients need to know their benefits, but this would be beyond that scope of expectations.

Thanks! The Anthem rep kept reiterating that for this kind of testing that he ordered, since it's genetic, he would also need to provide some sort of supporting justification/evidence on top of resubmitting with the correct code. Is that actually the case or is it more 'fluff'?
The rep listed three codes, which I think she indicated at least one of which would have needed to be specified for this to be deemed medically necessary:
"E75.10 Tay­Sachs disease,, G12.0­G12.1 Infantile spinal muscular atrophy, type I, other inherited spinal muscular atrophy,, or H35.50­H35.54 Hereditary retinal dystrophy"

So I'm assuming that means the doctor would have had to indicate at least one of those codes in order for this to go through...but as I don't think I have any history/indicators of any of those diseases/diagnoses, wouldn't that be 'unethical' for the doctor to specify?

Outside of this, does the fact that this has already gone to the point of being appealed (and denied) have any bearing on the success of the doctor resubmitting the claim even if it's with a correct diagnostic code? The rep told me "there's a 50/50 chance the claim will go through if you have the doctor resubmit" - again, not sure if that was some sort of BS to try to dissuade me.

[jeromedawg]

Agree with above. Here's what happened: When we order lab tests, each one has to have a specific diagnosis associated with it. It seems that in this case he used a generic diagnosis like "joint pain" (which is really a symptom, but that's a whole different rabbit-hole to go down) and not having something more specific (or even putting "hemochromatosis" if that's what they think you have). It's one of those "got ya" things that insurance companies do.

Here's how I would try to fix it: If you can get the physician to fix the diagnosis code, and fax their note along with your labs (including an iron panel, your CBC and your liver function tests), then the insurance company may process it. If they aren't even willing to try, then write a letter of complaint to their boss saying "my doctor ordered a very expensive lab test, the insurance company denied the claim because it was incorrectly billed, and the doctor is not willing to help me fix the billing problem."

I'm sorry this has been such a ridiculous wild goose chase.

I'm pretty sure I didn't have an iron panel done before - the doctor lumped that into the lab where he ordered the hemochromatosis analysis. But if I did have one, I don't think it was showing elevated levels of iron either. I have a feeling the physician isn't going to want to bother with this much more - he's already complaining about how he's spent a lot of time dealing with this as is. When you say "write a letter of complaint to their boss" - are you referring to Anthem?

[ETBen]

Without elevated iron levels, there was absolutely no reason to order that test. The codes she gave you can be used when there isn’t an elevatrdnoron level but of course you don’t have those.

Your 2 options are the state board or directly with the insurance or as a second level appeal. All disputing that the provider ordered unnecessary testing for which you should not be accountable. You won’t get anywhere with the actual doc from what it seems. When it’s their own claim and bill, it’s easier. Since it’s the lab, it’s easy for him to turn away and not care. I also suspect he has done this more than a few times and stuck pts with bills

[jeromedawg]

Without elevated iron levels, there was absolutely no reason to order that test. The codes she gave you can be used when there isn’t an elevatrdnoron level but of course you don’t have those.

Your 2 options are the state board or directly with the insurance or as a second level appeal. All disputing that the provider ordered unnecessary testing for which you should not be accountable. You won’t get anywhere with the actual doc from what it seems. When it’s their own claim and bill, it’s easier. Since it’s the lab, it’s easy for him to turn away and not care. I also suspect he has done this more than a few times and stuck pts with bills

I was ready to draft him another email but I suspect he will be of no help or use. He says his main reasoning to have the labs done was to "rule out" the possibility of hemochromatosis but it sounds like he still should have confirmed the iron levels directly beforehand rather than rushing in head-first. Is it of any benefit to him to order an expensive test on behalf of his patients that may or may not be "necessary"? Does he get some form of 'kickback' by doing this? It seems super irresponsible. I will write in to the insurance company in this case for the second level external appeal with the emphasis on holding the provider responsible for this poor decision. If the external review appeal gets denied then I believe I still have the option of going through the state board AFAIK.

I'm wondering if I should, at the same time, write a letter via the "financial assistance" avenue to the lab (Quest), also pointing out the same thing in that the claim was denied because the provider ordered unnecessary lab work/analysis, to also see if they would either reduce the amount or waive it completely.  Or if I should just not bother with that right now and only do that as the very last resort.

Anyway, thanks for all your help/advice and pointers. This has been super helpful as I'm struggling through all the BS.

[Abe]

Regarding contacting his boss: If he works for a group practice, and is not the head of the group, find out who the head is and contact them. If he works for a department at a hospital, find out the chair of the department. If he's solo, or head of a group, then unfortunately not much to do other than complain to the state board, since he's his own boss.

It's worth contacting the lab and explaining the situation. I doubt they'll do anything, but couldn't hurt.

[jeromedawg]

Regarding contacting his boss: If he works for a group practice, and is not the head of the group, find out who the head is and contact them. If he works for a department at a hospital, find out the chair of the department. If he's solo, or head of a group, then unfortunately not much to do other than complain to the state board, since he's his own boss.

It's worth contacting the lab and explaining the situation. I doubt they'll do anything, but couldn't hurt.

Thanks. I did contact the lab and there's nothing they can do and only offered that I could request "financial assistance" through which I could potentially use as an avenue to 'appeal' to them.

As far as his boss, he runs his own practice but I see he is also associated with a local hospital. But just because he's associated with the hospital doesn't mean that he works *for* them right? I'm assuming he's his own boss simply due to the fact that he has his own office (not in the hospital but nearby) and thus I think his own practice. Outside of that, I'm not sure how to determine/discern or differentiate if he "reports" to anyone...

[Abe]

Yeah, a lot of people are affiliated with hospitals but are essentially independent contractors with their own offices. That sounds like the case with this guy. I'd try the financial assistance route if you qualify. Last idea, and really grasping at straws: write a yelp review complaining about this.

[Freedomin5]

You should also be writing a poor review about your insurance company. Sometimes it's not the doctor's fault that your claim was denied. It's because your policy benefits don't cover a certain diagnosis, in your case "joint pain". You can't expect the doctor to lie or "change the diagnosis" just so you can get coverage.

[jeromedawg]

You should also be writing a poor review about your insurance company. Sometimes it's not the doctor's fault that your claim was denied. It's because your policy benefits don't cover a certain diagnosis, in your case "joint pain". You can't expect the doctor to lie or "change the diagnosis" just so you can get coverage.

That might be true, except I would also assume the doctor knew what he was doing when he ordered this very specific genetic test. It doesn't seem like a very common thing to order, and if that's the case some sort of forewarning (at the very least) for me to verify with insurance should have been in order (as a patient, and I think most other people are the same, I'm typically going to trust that my doctor and or his staff know what they're doing as far as the medical coding side of things so I don't have to worry about getting hit with claim denials...). Or, if the way to avoid all this would have been as simple as testing for iron first *before* going through with hemochromatosis, why didn't he just do that? To me it just seems like a classic case of "oh sh!t i jumped the gun....oops my bad sorry can't help you now"

[hops]

I would consider leaving a review even if the doctor's able to help you work this out (in which case, I'd also stress that they came through in the end), simply on the basis of this:

I saw this doctor for a second opinion and this is what I get... he seems nice, warm and caring but his wife/front office is terrible and they even skimped on printing and copying. They were hesitant to print/copy anything and then reused paper that had been printed on (just flipped it over) with the lightest ink setting possible (that or they were running the cartridges dry). His wife/admin also didn't know what an "invoice" is so printed out the procedures done and had the doctor write explanations... ?!? So bizzare. Its as if they don't have an actual invoicing system.

That's information prospective patients should know before seeing a specialist who could potentially order a bevy of expensive tests. Rheumatologists sometimes order thousands of dollars in testing at once, for a single patient (the cost of which is then reduced, often significantly, via an insurer's negotiated rate). If their offices aren't equipped to deal with coding and billing headaches (or minimize them in the first place), that's a cue to stay away.

[DaMa]

You've gotten lots of good advice here.  The only thing I didn't see listed that I would also do is write a letter to the CEO of the insurance company.  It really does work, and I know this, because I worked at a large insurer and had to do follow up on several of these letters.

I had to pay $700 in lab work this year that was totally unexpected.  My DH saw a therapist for a few months.  The clinic he went to has a policy to do drug screening on all patients.  We have a high deductible plan.  Never even crossed our minds that we would be paying for the screening, and I was SHOCKED at how much it was.  Shocked and livid.  They tested for like 50 different drugs and each assay was $20-$50.  At least we have the money to pay -- I wonder how many of their patients are just wrecked by that.

[jeromedawg]

I would consider leaving a review even if the doctor's able to help you work this out (in which case, I'd also stress that they came through in the end), simply on the basis of this:

I saw this doctor for a second opinion and this is what I get... he seems nice, warm and caring but his wife/front office is terrible and they even skimped on printing and copying. They were hesitant to print/copy anything and then reused paper that had been printed on (just flipped it over) with the lightest ink setting possible (that or they were running the cartridges dry). His wife/admin also didn't know what an "invoice" is so printed out the procedures done and had the doctor write explanations... ?!? So bizzare. Its as if they don't have an actual invoicing system.

That's information prospective patients should know before seeing a specialist who could potentially order a bevy of expensive tests. Rheumatologists sometimes order thousands of dollars in testing at once, for a single patient (the cost of which is then reduced, often significantly, via an insurer's negotiated rate). If their offices aren't equipped to deal with coding and billing headaches (or minimize them in the first place), that's a cue to stay away.

Yea, I'm planning to leave a review on Yelp at least. That was one of my cross-references [not my only, lol] when researching for a doctor. His wife, who *is* the front office staff, is pretty clueless and unhelpful. They are nice people, and I'm sure he's a great doctor. But they seem unable (and unwilling) to keep on top of things for all their patients... it seems like the doctor is left having to deal with helping her on the front office end, which is bad because it leaves very little room for him to make better informed medical decisions. Very bad sign.
Another bizarro thing is that, instead of typing out his letter of explanation, he HAND-WROTE the entire thing! While I appreciate the effort (which he kept reiterating regarding how much time he's spent on the matter thus far), that's just ridiculous...! Hire some competent staff and be willing to pay them a piece of your *VERY LARGE* pie to make sure that the patients at *YOUR* practice are treated right! I think and I'm betting he's nearing the retirement age though where he just doesn't give a crap...

[jeromedawg]

You've gotten lots of good advice here.  The only thing I didn't see listed that I would also do is write a letter to the CEO of the insurance company.  It really does work, and I know this, because I worked at a large insurer and had to do follow up on several of these letters.

I had to pay $700 in lab work this year that was totally unexpected.  My DH saw a therapist for a few months.  The clinic he went to has a policy to do drug screening on all patients.  We have a high deductible plan.  Never even crossed our minds that we would be paying for the screening, and I was SHOCKED at how much it was.  Shocked and livid.  They tested for like 50 different drugs and each assay was $20-$50.  At least we have the money to pay -- I wonder how many of their patients are just wrecked by that.

Interesting idea! Maybe I'll do that and send a separate letter to the CEO. Should I do that after exhausting all my options? Or in parallel with requesting the external review? Sorry to hear about all the other BS you had to pay for... crazy how much the testing ends up being for this stuff.