Author Topic: My doctor referred me to an out-of-network lab. What next?  (Read 3886 times)

xenon5

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My doctor referred me to an out-of-network lab. What next?
« on: June 29, 2015, 06:47:50 PM »
Hey All,

I went to my doctor for a routine checkup back in January.  He referred me for blood work at a local Quest lab and told me it was in-network, and when I asked the lab tech whether my insurance was in-network, she also said yes.  I received no invoices other than my check up bill from the doctor in February.

Flash forward 6 months and out of the blue I get an explanation of benefits from my insurance company saying that the blood work was invoiced for $700 out of network with no coverage at all.  I haven't actually received the bill yet but I imagine it will be arriving shortly.

I asked my doctor for a written prescription so I could find a place to go on my own, but he insisted that I go to this particular lab and that it was in-network for me.  He said it was against their policy to offer traditional prescriptions any longer.  Even if I needed a penicillin prescription, they wouldn't give me a plain slip - they only call in prescriptions.

I called the doctor's office and told them what happened.  They told me to call them back and fax the bill once I receive it.  But I'm still thinking about what my next escalation point will be to get as much as possible of this bill written off.  Here are some of the options I've thought of:

1) Make an appeal directly to the doctor/doctor's office.  Swear to never come back if they can't cover most of it (though honestly, I probably won't go back anyway)
2) Make an appeal to Quest.  I've found some accounts of people being successful taking this path but it seems like a long shot.
3)Make a claim appeal with the insurance.   An in-network doctor refused to give me the tools I needed to manage my own healthcare costs after all (ie, refusing to give a written prescription to use at any lab and coercion to visit the lab he preferred)

Now I know to never, ever go anywhere or do anything new related to my health without calling my insurance first.  And to repeat the process every year before appointments with doctors I've already visited.  What a crappy reminder!

forummm

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Re: My doctor referred me to an out-of-network lab. What next?
« Reply #1 on: June 29, 2015, 06:52:35 PM »
I'm sorry to hear this. The insurance system is terrible. Such a burden on you. And a burden on them every time you have to call. What a waste of everyone's time.

A lot of insurers have a website where you can look up what's in your network. Does the lab show up there? That would be a good way to argue with your insurer to cover it.

xenon5

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Re: My doctor referred me to an out-of-network lab. What next?
« Reply #2 on: June 29, 2015, 07:05:59 PM »
I'm sorry to hear this. The insurance system is terrible. Such a burden on you. And a burden on them every time you have to call. What a waste of everyone's time.

A lot of insurers have a website where you can look up what's in your network. Does the lab show up there? That would be a good way to argue with your insurer to cover it.

I looked it up and actually did find the lab listed on their website.  It doesn't give the precise address of the lab, but there's only one Quest lab within the same city.
« Last Edit: June 29, 2015, 07:22:27 PM by xenon5 »

forummm

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Re: My doctor referred me to an out-of-network lab. What next?
« Reply #3 on: June 29, 2015, 07:10:10 PM »
I'm sorry to hear this. The insurance system is terrible. Such a burden on you. And a burden on them every time you have to call. What a waste of everyone's time.

A lot of insurers have a website where you can look up what's in your network. Does the lab show up there? That would be a good way to argue with your insurer to cover it.

I looked it up and actually did find the lab listed on their website.  Attached the screenshot.  It doesn't give the precise address of the lab, but there's only one Quest lab within the city of Teaneck, NJ.


That sounds like good evidence to me. Just make sure that your plan was selected to return this search result (since networks vary by plan).

You really couldn't have done more. I think your insurer needs to cover the claim as in-network. If they don't do it voluntarily, you can try appealing and then arbitration. But since it's on the website, and your doctor and the lab both said they were in-network, that's pretty compelling.

Pigeon

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Re: My doctor referred me to an out-of-network lab. What next?
« Reply #4 on: June 29, 2015, 08:03:54 PM »
Save screen captures of the website showing the lab as being on your insurance.

Axecleaver

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Re: My doctor referred me to an out-of-network lab. What next?
« Reply #5 on: June 30, 2015, 07:37:27 AM »
This is a pretty common occurrence. Call the lab and ask them to resubmit the claim. Often, the provider will run the claim and if any problems happen, they just give up and bill you for the full amount. It costs them nothing and maybe they get lucky and you pay it.

If the claim is denied again, you'll need to work it out with your insurance company. You may have out of network benefits you can use to lower the cost. A $700 lab bill is probably around $40-50 at insurance company negotiated rates. Price transparency is the biggest issue we have in the US insurance system right now.

yandz

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Re: My doctor referred me to an out-of-network lab. What next?
« Reply #6 on: June 30, 2015, 07:42:27 AM »
Axecleaver is right on.  Follow those steps.  I just want to say, don't worry about it too much. I work for a medical device company that sells a home medical product.  We regularly ask for and receive "in-network exceptions" for our patients even when we actually are out of network for them.  Which is to say, even if the insurance company continues to insist the lab was out of network, in-network exceptions are not a rare occurrence.  Just be your own advocate and I am sure it will get sorted.