Twice in the last year, once for my wife and once for my daughter their doc have has them go into lab XYZ for a panel of tests and in both cases tests were 100% negative but resulted in bills coming my way of over $1000.00 even with decent health insurance.

Now keep in mind, also in both cases there were no real medical issues to speak of. My wife was getting a general check up for work and mentioned she had been a little tired lately and my daughter had switched to anew provider that wanted a full blood panel done.

I do not have an extra $1000 laying around and even if I did I would still be pissed. I asked both doc offices and testing labs why this wasn't pre approved with insurance or why we were given no indication that they would not cover.

Doc 1 claimed the testing lab screwed up and should have and doc 2 has not replied.

I told both wife and daughter that, in the future, if any tests need to be done to ask the doc if they really need to be done and then ask lab to check insurance to determine coverage before hand, which will probably result in us walking out with no test.

Similar things happened at pharmacy when daughters dermatologist prescribed her a acne med. When I went to fill it I was hit with a $350.00 co pay. I told Walgreens they could keep it and called derma telling her that if this was a cancer or heart med I would not bitch but this shit was not happening....magically there was another drug that cost $15.00 that worked just as well.

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I told both wife and daughter that, in the future, if any tests need to be done to ask the doc if they really need to be done and then ask lab to check insurance to determine coverage before hand, which will probably result in us walking out with no test.

This is the correct procedure to follow, verify that the place/thing is covered by YOUR policy. Just because someones in the medical field doesn't mean they participate with every carrier.

My wife works in the health insurance field, does a lot of the training for group participants, one of the main things they do is continually inform people to verify that whatever your primary care physician is doing, ie, drug scripts, pharmacy, blood tests, any tests, the location where you are going to get the test, the specialist, the hospital, is covered by your policy.

Doctors don't care about your coverage, they only are concerned with obtaining the information they need to provide the care.

They also can't know what the carrier affiliations are for every medical provider within the geographic area around them, nor will their staff. For labs here there are several providers, only one is covered through our plan.

Go to the wrong place and you will have to pay, and the medical provider should tell you but they don't have to, you hand over the script for tests from Dr. Brown and they do the tests.

It's the patients responsibility to make sure you are covered, it's your insurance.

People hear that, but they don't listen.

Every month someone from some HR calls and wants to know why so and so's medical bill wasn't covered, sometimes its a billing code, many times its the patient went to a non participating location.

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It's the patients responsibility to make sure you are covered, it's your insurance.

Yet that's generally impossible to do. Nobody can tell you what anything cost. You have to get the bill to know what's in it.

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It's the patients responsibility to make sure you are covered, it's your insurance.



Yet that's generally impossible to do. Nobody can tell you what anything cost. You have to get the bill to know what's in it.

Both of these statements are correct. It is ultimately YOUR responsibility to pay the bill if your insurance company does not. Generally speaking it is advisable to call the physicians office and speak with the billing clerk to determine whether the doctor is "in network" or not. Insurance companies often do not update their lists and make plenty of mistakes in processing. Many of the contracts with the doctor's office require that referrals be made to "in network" labs.

As far as kickbacks are concerned, these sorts of arrangements are illegal, and should be reported if they occur.

Can you imagine just dropping your car off at a mechanic and agree to pay whatever they decide to charge you without getting an estimate beforehand?
Why is this so in the medical world?

This almost happened to me last month. I had some basic labs done at a new doctor. I saw the claim come in a few weeks later (on the mobile app) and it said “you may owe $1,208” .

The actual paper bill came in and I owed $135.

The negotiated discount with my insurance provider was $1,073 which brought it down to just $135.



I typically don’t pay anything out of pocket for labs (at my normal doctor).

Sorry for the drift. Cope how are you doing with kicking the addiction now? I couldn’t find your thread on it.

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Originally posted by a1abdj:

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It's the patients responsibility to make sure you are covered, it's your insurance.

Yet that's generally impossible to do. Nobody can tell you what anything cost. You have to get the bill to know what's in it.

Every benefit plan has a list of providers and services covered, anyone that has signed up for or bought a plan is given a card with policy number, group number if applicable, web access, and a toll free number, all you have to do is call.

Sadly people just take all physicians as an authority on the subject and go get things done without questioning anything. They will enter a facility present an insurance card and agree to services thinking that because they handed an insurance card to a receptionist they are covered.

Like was said you wouldn't drop your car at a dealer and tell them "fix it" without getting an estimate or finding out if they honor the warranty on your car.

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Originally posted by a1abdj:

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It's the patients responsibility to make sure you are covered, it's your insurance.

Yet that's generally impossible to do. Nobody can tell you what anything cost. You have to get the bill to know what's in it.

Yes and no. While the provider can not always tell you EXACTLY what something will cost (especially big items like surgery, etc. because they can't tell exactly what they will have to do until they do it - complications, etc.), for routine items like labs, office visits, etc. they can provide you with CPT codes which is how they bill the insurance carrier.

Most provider offices will verify your insurance remotely prior to your visit, but the verification is only as good as the info provided by the insurance company. Just as when you call your insurance company they may tell you that something is covered, etc. but they have the standard disclaimer "verification of coverage is not a guarantee of payment" or something like that. They can't say what will be paid until the bill actually arrives.

But you should be able to easily find out whether a doctor, lab, facility, etc. is in your insurance network. And I'd encourage you to ask about CPT codes, etc. for large ticket items (or if you're using an out of network provider).

I'm in healthcare and I can't tell you how many times we hear about patients thinking everything is covered just because they have insurance. As was previously stated, while the provider will try to keep services in network, they are under no obligation to do so. It is the responsibility of the patient to know their insurance coverage.

Its important to remember that the provider most likely has multiple contracts with various carriers, they want to be able to service anyone that comes into the office.

It's like a Merchant, they take cash, visa, mc, amex, discover, and debit etc. The difference is not every provider is a subscriber with all carriers, and they don't always opt into each providers levels of service. Some primary care practices are part of a larger group, and the doctors have no control over the billing and HC contracted services, they don't have a clue and don't care to know.

Dr. Schwartzenheimers Proctology clinic may or may not be with Aetna, your primary care may suggest him if you ask for a recomendation on who to scope you, but that doesnt' mean your Primary knows if Dr Schwartzenheimers practice is enrolled in Aetna.

Its just wise to validate with the carrier before you engage a service provider and create a bill.

At one dr, when filling out those payment responsibility forms, I added "Dr (the one I was seeing) is responsible for all bills for sub-contracted work not covered by patient's insurance."

The lady behind the desk threw a fit claiming I was not allowed to change anything on the documents to which I replied "everything is negotiable." The Dr came out, looked at what I wrote and told the lady "it stays."

Turns out, that lady is a sub-k of the doctor's office, her company is financially responsible for her mistakes, and she had a habit of NOT using labs covered by a patient's insurance (she was sending the lab work to "acquaintances"). Dr also had my note added to all new patient's forms and the lady quit soon there after.

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Originally posted by LS1 GTO:
At one dr, when filling out those payment responsibility forms, I added "Dr (the one I was seeing) is responsible for all bills for sub-contracted work not covered by patient's insurance."

I'm surprised. So if the doctor had referred you for an MRI and it went toward your deductible or ordered a test they felt was medically necessary but that your insurance company didn't then he/she agreed to pay it? I can't imagine many doctors agreeing to that - I know none of the one's I've worked with for the past 20 years in various practices would.

My experience has been that the doctors offices in my area must have had their fair share of patients who ended up with surprised bills. They make sure everything is covered before they set an appointment, refer to another doctor, tests, or prescriptions.

They're not staffed to harangue non-paying customers nor can they just turn to bill collectors for pennies on the dollar.

When I've tried to do my due diligence with Blue Shield, I've gotten conflicting or erroneous statements.

My prostate cancer doc's scheduling person contacted me to set a date for a procedure.

I told her that before setting any schedule, I needed to know in writing what, if any, costs I would be responsible for.

That was two weeks ago.

I'm still waiting for her to get back to me.

However, after my wife got hit with a FIVE HUNDRED dollar charge for a shingles shot from her new doc's office, I am not going to proceed with anything until I receive a worst-case cost statement.

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Originally posted by mojojojo:

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Originally posted by LS1 GTO:
At one dr, when filling out those payment responsibility forms, I added "Dr (the one I was seeing) is responsible for all bills for sub-contracted work not covered by patient's insurance."

I'm surprised. So if the doctor had referred you for an MRI and it went toward your deductible or ordered a test they felt was medically necessary but that your insurance company didn't then he/she agreed to pay it? I can't imagine many doctors agreeing to that - I know none of the one's I've worked with for the past 20 years in various practices would.

In my experience, when the dr. does a referral the patient just needs to tell his/her admin (who ever is making the referral) to make sure the sub-k provider is in the patient's network. Your doctor does know what your insurance is and what is covered and they can easily ask the sub-k provider.

In the case above, I just had the stipulation added up front.

I went in for a physical a few years ago and the regular lab tests were coded as "illness" rather than "preventive". My insurance hardly covered any of it and I got a huge bill. My doctor would not change the coding. How Vitamin D, and cholesterol are related to the fact I've had elevated blood pressure a bunch of years ago is beyond me.

One doctor's office told me I could get 'pre-authorization' for any lab tests or treatment to see how they could be covered. They went on to say it's extra work for the staff and they may not want to do that. If they won't, the only other option it to get the codes for the proposed treatment and try calling the insurance company yourself.

I've had relatively good luck calling the insurance company about things to see what's covered and the best way to handle it. Several times they told me of 'preferred providers' to use where the costs were much lower than if I used what the doctor prescribed.

Some years ago I was sent to Labcorp in Tucson for blood work up. Labcorp made me sign a form authorizing them to bill me for charges not paid by insurance. Blood work included PSA test which is always paid by Medicare.

Of course Labcorp screwed up the code for PSA and charges got bounced back. Something like $217.

I told Labcorp to correct the code and they refused to do so, telling me I had to pay.

I told them to correct their mistake and not bill me.

They didn't bill me again and I never went back.