Ever dispute a doctor's charge?

[KarenAylwood]

I went to a new doctor in February as I moved and needed a primary care doctor on my new insurance. He did a physical, along with some bloodwork. I figured- hey, the doctor says I need it, so I didn't even think about if insurance would cover it or not.

So then two weeks ago I get a bill for $250 from the doctor's office saying that my insurance paid $X amount and I owe $250 for everything else. It was for specific blood chemistry tests that he had done. My DBF (in medical school) said that a few were tests that should have been done if I was sick, and weren't normally routine for an annual physical.

I want to call the office and tell them that it was a routine yearly physical so I shouldn't have gotten any tests that were not routine. How should I go about this? Call my insurance and yell for them not covering it, or call the doctor and yell for it being done in the first place?

Please help! This $250 bill isn't exactly figured into my budget

 

[Liliyana]

Have you checked with your insurance to make sure they really don't cover it? Something like this happened to me late last year. But my insurance *did* cover it, and had paid them fully... doc's office was just attempted to double-dip, I guess you'd say

 

[It's A Happy Day]

1st ask your physician for an itemized bill
Then call your insurance and ask them what they paid for and what they denied and why they denied anything if they did.

I do medical billing and when we bill the insurance company there are agreed upon rates. Even though our standard cost may be say $125 the insurance company may only pay at $90 so the remaining is written off as "contractual allowance" It may be that the physician is trying to recoup some of that "extra" cost over the prorated amount. You are not liable for that and he should not be billing you that. It also could be that they billed the insurance co. and the ins. co. denied saying you had a co-pay. Some policies are set up 80/20 (or other percentages) with a limit on how much you pay out before the insurance picks up the rest.

I would definitely question it. Sometimes it is just human error as well! Good luck!

 

[Tink-aholic]

I also used to do medical billing and another likely explanation is that the insurance did an invalid denial. Many insurances deny lots of things they are supposed to cover just to see if anyone catches it. Lots of doctor's offices just pass on the bill (instead of going back to the insurance to demand the money) and you would be SHOCKED at how many people just pay those bills!

If you were required to pay anything at all, you would have received an Explanation of Benefits (many of them are online now) detailing exactly what you were responsible to pay and why. If one penny of that is more than your contract allows, go back to the insurance and hold them to their contractual agreement.

Also, write down the name of each person you speak to and the time of the call. It may take a while, but it will be worth it.

Good luck.

 

[bmoncher]

You have several options for the bill, one ask your insurance for a review, did you get an EOB form that indicates what they paid for?
Second, you can ask for the office to not balance bill you (but that is really based on your insurance contract if they can or cannot)
Third you can get a payment plan, as long as you pay 5 a month, they cannot send you to collection or charge interest...


And as far as the lab work, I don't know what you had done, so I will not comment except to say many tests we do when people are ill are also used as baseline screenings. Did you have old records sent to the new MD? or was he starting fresh? As a matter of fact other then a C-reactive Protien or some specific Liver studies that I can think of off the top of my head that could be screening...

 

[Tink-aholic]

Third you can get a payment plan, as long as you pay 5 a month, they cannot send you to collection or charge interest...

I agree with everything else you say but the above. That is a common misconception about paying $5 a month. They can send you to collections for any amount that is past due...or can take you to court to obtain a judgement against you. Any amount overdue can be charged interest if it was known about in advance.

That said, if you do truly owe the bill (after you find out about insurance and balance-billing), then you can ASK for a payment plan. I would often take 50% of the bill if I could get the rest in one or two payments. Be polite -- It really does go a long way.

Good luck.

 

[wwallydoc]

Speaking as a physician I can say there are some common misconceptions. First of all Screening or Routine labs are NEVER covered. You must have a reason (the physician) or the test won't be covered. If that were the case, when you went for lab testing the lab tech should have informed you. Most likely what happened is that you insurance requires you pay a deductible before they cover anything OR a wrong code was used. As far as double dipping referred by someone else---Dont see how that would happen---so many mechanisms are in place now that a phyisican would be caught for doing such a thing rather easily---I would call the physicians office and ask to speak to the person responsible for billing and they may be able to tell you what happened. If that doesn't help check with the insurance company. Sad to say but as patients we are ALL having to pay more and more (premiums,co-pays,deductibles) and are getting less in return

 

[msmayor]

Speaking as a physician I can say there are some common misconceptions. First of all Screening or Routine labs are NEVER covered. You must have a reason (the physician) or the test won't be covered. If that were the case, when you went for lab testing the lab tech should have informed you. Most likely what happened is that you insurance requires you pay a deductible before they cover anything OR a wrong code was used. As far as double dipping referred by someone else---Dont see how that would happen---so many mechanisms are in place now that a phyisican would be caught for doing such a thing rather easily---I would call the physicians office and ask to speak to the person responsible for billing and they may be able to tell you what happened. If that doesn't help check with the insurance company. Sad to say but as patients we are ALL having to pay more and more (premiums,co-pays,deductibles) and are getting less in return

Not so sure I agree with that. When DH and I have our routine physicals every year, our doc orders a slew of bloodwork as part of that physical and its all covered at 100% under my plan.

In all honesty, I've never paid dime-one to the lab that does any of my testing; its all covered at 100% as long as the doc has done the paperwork correctly.

To the OP, its entirely possible that your insurance plan won't cover a specific test if the diagnosis code used to order the test doesn't 'match' the need for the test. Sometimes it can be off just a digit or so. Its also possible that the insurance plan you have just doesn't cover that test at all.

The thing is, its never up to your physician or his office to know your insurance coverage. There are too many variations to each and every plan for them to know. Its always up to us, the consumer, to have that knowledge.

That being said, I am with you in the thinking that "If the doc thinks I need it, I get the test". This is why he/she spent years in med school and not me. In these cases, its up to us to say to the doc "Can I delay this test for a few days so I can check my insurance coverage?", or "Can I get the information on the coding to see if this test is covered?". It can be frustrating to attempt to get the answers, but it is possible.

 

[jamesmommy]

I would call my insurance company. I know in our case, we can not have testing done in office anymore, as the testing company used by our doc's office is not covered by my insurance We now have to go to a seperate facility with our doc's orders and have the blood drawn there.

 

[Lisa loves Pooh]

Not so sure I agree with that. When DH and I have our routine physicals every year, our doc orders a slew of bloodwork as part of that physical and its all covered at 100% under my plan.
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Depends on your plan. All my lab work, routine or otherwise is billed separately. Even at the hospital. They have their own codes and their own co-pays (15%).

My first labwork with my pregnancy was to the tune of my share being over $100. I questioned my OB and they were more than okay with explaining what they requested and what was done and why it cost more. Since I consented, not much I can do. Though if we go for number 4--I will make sure I know all they are sending out for ahead of time.


OP--just get an itemized statement and fullly understand your policy. If something doesn't make sense..ask. You are within your rights to do so. (In my experience, as long as you keep the doctor/hospital informed, they will honorably not send you to collections. Though as someone posted--they at some point will be within their rights to do so. Though often--once paid, it is an overlooked item on your credit report as long as you can explain yourself on a medical payment collection and it has been paid. Been there, done that!)

 

[KLAIT]

I am the Benefits Admin in our company and we see this happen for a few reasons. First, it is the individual responsibility to understand their own medical coverage. For instance, our plan has a set dollar amount to cover an annual physical..it offers a $500 physical benefit...anything over and above that is not paid. We have made a huge effort to educate our employees on what their policies cover and do not cover as it can really leave a mess for them later.

Second, there are errors made in the billing department of the Dr offices/ hospitals...

The first thing I would do is call the insurance company and ask why it is being denied and then work your way from there. You may find that the claim was billed incorrectly or that the policy just doesn't cover the specific service.

Good Luck.

 

[NVDisMom]

I have found that 90% of the time medical claims for my family are not paid/billed correctly. I make it a habit to not pay a single dr bill (other than the required copay before the visit) until I receive the explanation of benefits and the dr bill with codes. The dr's office is aware of my procedure, as well as the dentist, and are okay with it. Usually I find something wrong that saves me money. It can take months to get it straightened out. Depending on the insurance company it can be like pulling teeth to get it fixed.

A side note...my insurance company pays 100% for one routine physical every twelve months, including lab work ordered. Usual and customary or contractual amounts apply. Check your EOB, there should be column that lists amounts that the patient is not responsible for. NEVER pay these amounts. The office is under contractual obligation to write off that amount and cannot charge you.

 

[Kickapoo Joie Juice]

A good lesson I learned: NEVER go into the doctor without a complaint. Even if it's just a yearly routine checkup, claim "abdominal pain" or "migraines" or SOMETHING.

That way, all the stuff that insurance agencies refuse to pay for for "routine" checkups (including cholesterol for my husband-wth!!!) gets paid for because you came in with a complaint that the doctor then used the labs to diagnose.

It's the only way to get our insurance to cover cholesterol testing, and some other routine preventative health tests (like colorectal cancer screens) that I feel are important for our family's health.

 

[Halle]

Kickapoo Joie, it may not be wise to complain about a symptom that you don't have, you may undergo unnecessary testing and you may be adding to the rising costs in health insurance.

 

[jennifer293]

Our insurance only covers use of certain labs in our areas, so when I have them done I have to make certain they are sending my samples to the right place for it to be covered. It is really a pain, but I don't want to pay it.

I had gestational diabetes and 19 months after I had my DD I went for my regular GYN visit, and while talking to my Dr. I told him I was not feeling well so I asked him to do another glucose test on me. He did that and a few other tests to rule out everything. Well it turned out that the diabetes never went away. About 3 weeks later I get an EOB saying that none of those tests were paid. I call the ins. co. and they said the reason they were not paying was because since he was an OB/GYN and I was no longer pregnant that he was not authorized to do those tests. They then said that the dr. knew he was not authorized so his office cannot charge me for this either. So I call the dr. office and they tell me that they will eat the costs of all the tests and if I need anything else from them just let them know..It was almost $800.00 in testing and I never got a bill. That was almost 2 yrs ago and it is not on my credit report either..

 

[NVDisMom]

I have had problems with my insurance company paying for immunizations b/c they are only allowed to be done during a routine check up and the dr had put a diagnosis on the chart...teething! ...don't all 6 months old teeth? So be careful with charting symptoms when you are there for a routine physical.

I don't like Michael Moore, and I have not seen his latest "documentary", but I was reading a description from a viewer. In the movie they describe insurance company practices. Including a policy of blanket denial of claims at least 10% of the time. It would be interesting to know if this were true. I honestly wouldn't be surprised.
Jennifer 293...most insurance companies will allow an ob/gyn to act as their primary dr for annual visits, b/c all women should be having pelvic exams as part of their physical. So I would challenge their refusal of the tests. OB/GYN's are not for pregnant women only.

 

[Cindi0511]

My OB/GYN IS my primary care. If I have a problem with anything, he gets me. Fortunately, I haven't had to fight with anyone lately, but my poor sister has. I think they finally got everything straightened out -- 7 months later -- but at least it's done.

 

[Kickapoo Joie Juice]

Kickapoo Joie, it may not be wise to complain about a symptom that you don't have, you may undergo unnecessary testing and you may be adding to the rising costs in health insurance.

I would never lie about a symptom. However, when I go into my doc, I ALWAYS have a complaint. This is what works for me with my current insurance company, after enduring basic medical expenses being rejected left and right, and only after I fight the insurance company and present documentation, etc, was I getting stuff even covered. I go in, tell the internist I'm having migraines, which I do, occasionally, she puts "migraines" in under diagnosis instead of "routine physical" and I have no trouble with things bouncing.

If the stupid insurance worked the way it should, I wouldn't have to go through all the idiot machinations to get decent care.

And believe me, with a bunch of nurses and physicians in my family, I know *exactly* what I need and don't need in terms of tests. When it comes to my body, I'm a freakin' expert, and I'm not letting the insurance company dictate my quality of care. I, and my doctor, decide that.

 

[KarenAylwood]

OP here. Thanks for all the replies!

I did get an EOB, but that was back in March after my appointment was in February. Then I got a bill just recently for it. I had gone to the doctor another time with symptoms in April and got the bill in May so I just assumed the doctor ate the cost of the bloodwork from February. Until I got the bill.

I've been working tons of overtime lately and haven't had a chance to call my insurance company yet. I didn't completely understand the EOB, as it didn't give an itemized list of what was done and why it was denied. It was just 5 lines of "lab work" and how much it cost/how much they paid. The doctor's office did send me an itemized bill with the amount, so I'm going to take that and call my insurance this coming week to see why they didn't cover it.

If the insurance company will not pay it, I will be calling the doctor's office to get an explanation as to why it was needed. Hopefully I can get this figured out. I'm not happy about paying the bill. I can pay the bill, but if I can avoid it I will!

Thanks for all the help. This whole situation is just making me not want to go to the doctor

And what makes it even worse is that DBF is working rotations in a hospital nearby where they see uninsured patients. I'm paying a bunch of money for my insurance, and still being billed while these people are just walking in uninsured and not paying anything!!!

 

[msmayor]

I kind of went back and re-read this, and wonder if the problem isn't the tests themselves but where they were done.

Did you go to a separate lab for the tests, or was the bloodwork done right in the doctor's office?

Believe it or not, many insurance companies require lab work to be completed in one of their participating labs. A few years ago, when DH and I tried to save a little on our health premiums, we were with an HMO that required us to use a specific outpatient lab for all bloodwork and related testing. It was a horribly cramped office where no appointments were taken; it was all first-come-first-served and one day we waited two hours just to have some blood drawn. It was awful.

Our primary had the facilities in his office to do the tests right there, but we had to decline and use the lab because of coverage.

Just wondering if that's where the denial is coming from...