Health insurance claim denial/network issue

[Susie]

I recently had genetic testing done to assess hereditary cancer risk.  My doctor assured me that the diagnostic company was really helpful with insurance, they verify insurance coverage for the test between receiving the sample and actually doing the test, and that coverage should be no problem with my family history.

Sure enough, a few days after I provided the sample, I got an email from the company that correctly identified my insurance company, expressly indicated that they were in-network for that insurance carrier, and estimated my responsibility as $20, which is my usual copay.  Cool.  They did the test, sent my results, and billed insurance.

My insurance denied the claim, saying the diagnostic company is not in fact in network.  They sent me a check for $103.xx which is what they are willing to pay, and I'm responsible for dealing with it from here.  I haven't been billed directly yet, but I'm sure it's coming.  I've seen the explanation of benefits from my insurance carrier so I know they originally billed my insurance carrier around $1200.

What's the likelihood that this can be negotiated to something reasonable?  If they had not misrepresented their network status with my insurance provider, I'd never have proceeded.

[msmerymac]

I would push back with your insurance company first.

Also, your insurance company should have an amount that they would USUALLY pay for that type of procedure. Even if your portion was a $20 co-pay, the insurance company would usually say, "We're paying $680 of this $1200 charge," pay the testing company, and everyone would be fine with that. I know with high-deductible plans, the insurance company says, "We're paying $680," but then you become responsible for that amount (before reaching your deductible). So there's a distinct possibility that you'll end up "owing" a lot less than $1200, but I'd still have the insurance company review the claim.

[sadlebred]

If you get nowhere with the insurance company, file a complaint with the state Insurance Commissioner or State Insurance Board. They will require to you prove you have tried to resolve it, so keep track of all correspondence, calls (time, who you spoke with), documentation etc. It's the last effort but can bring good results quickly.

[mccallister84]

I would wait until you get a bill from the testing company honestly.

[nospaekae]

Aug 9, 2018 10:46:41 GMT -5 sadlebred said:

If you get nowhere with the insurance company, file a complaint with the state Insurance Commissioner or State Insurance Board. They will require to you prove you have tried to resolve it, so keep track of all correspondence, calls (time, who you spoke with), documentation etc. It's the last effort but can bring good results quickly.

This. I posted about a similar issue last year on ML. In my situation, I confirmed with my insurance that a therapist was in network. After a few appts. I got the EOB and insurance was claiming she was out of network. After 6 months or so of multiple appeals, I took it to the state insurance board. Insurance changed their tune and paid in less than 10 days.

You should also be able to look up Drs/labs in your network on your insurance website. If the lab is listed, I'd screenshot it as proof.

Any chance you're dealing with Aetna?

[Susie]

Aug 9, 2018 9:58:20 GMT -5 msmerymac said:

I would push back with your insurance company first.

Also, your insurance company should have an amount that they would USUALLY pay for that type of procedure. Even if your portion was a $20 co-pay, the insurance company would usually say, "We're paying $680 of this $1200 charge," pay the testing company, and everyone would be fine with that. I know with high-deductible plans, the insurance company says, "We're paying $680," but then you become responsible for that amount (before reaching your deductible). So there's a distinct possibility that you'll end up "owing" a lot less than $1200, but I'd still have the insurance company review the claim.

Supposedly the $103 check that they sent us is that amount, which is obviously not much toward the bill.

I would be fine with signing over the $103 + paying the $20.  But that is so far below the original amount they billed that I am concerned about what kind of mid point we can possible reach that would be acceptable to everyone.  I'm also worried about them trashing my credit while we hash this out.  I've read so many horror stories.

Fucking health insurance in this country, man.

[Susie]

Aug 9, 2018 11:14:05 GMT -5 nospaekae said:

Aug 9, 2018 10:46:41 GMT -5 sadlebred said:

If you get nowhere with the insurance company, file a complaint with the state Insurance Commissioner or State Insurance Board. They will require to you prove you have tried to resolve it, so keep track of all correspondence, calls (time, who you spoke with), documentation etc. It's the last effort but can bring good results quickly.

This. I posted about a similar issue last year on ML. In my situation, I confirmed with my insurance that a therapist was in network. After a few appts. I got the EOB and insurance was claiming she was out of network. After 6 months or so of multiple appeals, I took it to the state insurance board. Insurance changed their tune and paid in less than 10 days.

You should also be able to look up Drs/labs in your network on your insurance website. If the lab is listed, I'd screenshot it as proof.

Any chance you're dealing with Aetna?

No, not Aetna.

The plan that we have lists "Counseling and evaluation for genetic testing of women for BRCA breast cancer gene" under covered preventative services, which is what I had done.  I am having trouble searching providers though because the drop down list only lets you search providers that are X miles from your in-state zip code, with 100 miles as a max.  The test was done by Counsyl, which is in CA (I am in NY, my doctor is in NY, etc.).  I also am not sure if it has changed since I had the test done in July; on 7/31 Myriad Genetics bought Counsyl (which is who did my test).

Interesting though:  www.fastcompany.com/3059072/why-patients-are-getting-hit-with-surprise-bills-after-genetic-testing  

While a shitty story, it is encouraging that they will probably eventually take a significantly reduced amount, but we may need to go through a long, PITA appeals process first.

[raangoli]

I had a situation with NIPT, except the office was upfront that my insurance may not cover it. The office advised if/when it gets rejected by insurance, I should call the lab and negotiate with them directly. The lab reduced the billed amount significantly without any pressing from me.

It's really ridiculous, but that seems to be the how things work with insurance lately.

[chimera]

I had one genetic panel that was a $7k bill -- it turned out it was a billing error on the lab's side. They'd submitted it under the wrong provider ID number - they'd used the pathologist's individual provider ID instead of the one associated with this lab that was in network with this insurer.

[steamboat185]

I’d wait for a bill from the testing company. I had testing done when I was pregnant where they billed my insurance company 12k. Insurance said NO and the testing company sent me a bill for under 100 dollars, which was what the doctor estimated. Just because the bill the insurance some crazy high amount doesn’t mean that is what you will owe.

[winemaker06]

I’m not much help. But FYI I heard recently that medical debt doesn’t get reported on your credit until something like 120 days overdue. So you do have time.
Good luck fighting it!

[wildrice]

I actually think that if the healthcare provider told you, in writing, that they checked and your insurance would cover it - they should credit you the bill. It was their mistake.

I don't know that I'd start with that, but if comes down to your insurance denying it forever, I'd fight the company who did the testing. They should not have told you that if it wasn't true/verified.

[tacom]

When we did NIPT, we had no insurance coverage. They billed United something like $2,500 and I think I paid $250 after calling (my doctor was up front that this likely wouldn't be covered as I wasn't AMA and shared what his patients usually pay OOP)

I got burned by a provider (chiropractor) who confirmed my insurance plan covered services in network (should have been just a $30 copay); I did not verify myself with insurance... ended up getting billed something like $1,500 and settled for $500ish. I'm still pissed, but now I know to call insurance myself with the tax code before initiating care.

[nessness]

I would call the company that performed the testing.

I tested positive for the CF gene while pregnant, so my H was tested too. The insurance company paid for my test but denied H's. I called my doctor and the insurance company with no luck, but then I called the testing company and they immediately offered to reduce my bill from like $600 to $30.

[icedcoffee]

I did some tests with counsel and even though they bill insurance over $1,000 for it the OOP amount they bill patients is $99 so I’d wait to get a bill.

[mrs.jacinthe]

Contact the healthcare company. If they confirmed they were in network with your provider, they need to handle the bill appeal. It's possible (and likely) someone made a mistake in the billing department and billed this incorrectly.

And don't cash that check yet, if you haven't already.