The Medical Billing Snafu

About six weeks ago I went to the doctor’s to have some blood work done — routine stuff, mostly cholesterol, nothing my health insurance had ever balked at before. I remember my doctor saying in passing “I’m going to send it to the good lab this time”, but I didn’t think anything of it at the time.

Two weeks later, I got one of those “Explanation of Benefits” from my insurance company. Normally I just glance at these, take solace in the friendly “This is not a bill!” printed at the top, and then shred them. This one hilariously had 17 separate line items, all just identified as “Medical Services,” but, somewhat unsettlingly, also included a check for $464.43. As a pessimist, I knew this couldn’t possibly mean anything good.

I called my health insurance company and the (actually quite nice) human I talked to there gave me the scoop: the “good lab” my doctor sent my blood work to was not in my provider network. The $464.43 was what my insurance had agreed to pay for out-of-network testing; the lab would be sending me be a bill for their full charges, which would be around $1,400. He suggested that, when I got that bill, I call the lab and see if they’d just accept the $464.43 (which he said they might, which sounded insane to me) and that if they didn’t I should file an appeal with my insurance company, which he was confident would be accepted since this wasn’t a service or lab I had requested.

That was a month ago. I still haven’t received a bill from the lab. My questions:

* Should I go through the trouble of contacting this “good lab” to see what’s up? My strong instinct is that if I haven’t gotten a bill, it’s not my problem, and I should leave well enough alone. But a few years back I had a medical billing headache that resulted from one of my wife’s doctors submitting a claim to our insurance 18 months after her visit, so I know these things can lurk for one reason or another and probably should be dealt with sooner or later. (I would need to cash the check from my insurance by September, for what that’s worth.)

* Assuming I do eventually get this $1,400 bill, should I wait to go through the appeals process before I give my doctor’s office holy hell? Even if the appeal is approved, should I still complain to my doctor? If it isn’t, is there any chance that the doctor would cough up the $950 difference?

* Even if everything does work out in the end, is this a bad enough violation to dump my doctor over? I like her because her office is an easy walk from our house and you can always get an appointment on short notice if you’re sick. It’s a tiny one-doctor practice and her support staff is not always the best, which has resulted in the occasional minor billing snafu, but nothing on this scale. I relayed the “good lab” comment to the guy at the insurance company and he darkly suggested that sometimes doctors have sketchy relationships with particular labs.

Anyway, curious as to what you and other Billfolders think. The good news is that I managed to get my cholesterol down from the upper 190s to 151 in only six months! Eating better and exercising daily really does do wonders. — J.

Our health care system is quite something isn’t it?

Regarding your first question about contacting the “good lab”: A common story I often hear about has to do with someone applying for a loan or a line of credit and being turned down because of a medical bill he or she wasn’t aware of that ended up going into collections. This, plus the medical billing headache you experienced previously, would prompt me to get this all sorted out sooner than later.

As for your second point, I would—politely—talk to the doctor about the billing issue regardless of what happens and have your doctor make it clear to you when you are getting a service that’s out of your network so you won’t have to deal with this again in the future. I would wait to see if the appeals process goes through or not before bringing it up, and if it doesn’t, I’d ask your doctor for her help in negotiating the bill.

Personally, I don’t think this is worth dumping your doctor over—especially if the appeals process gets approved, or you’re able to negotiate your bill. If you like your doctor and the services she has provided you (besides this snafu), I’d stick with her unless the billing becomes a problem again.

One last thing: If the bill doesn’t make it through the appeals process and you have difficulty negotiating it, there are health care billing advocates that may be able to help: Medical Billing Advocates of America is one, and the Patient Advocation Foundation is another.

In any case, congrats on getting your cholesterol down! Thoughts from readers?


Photo: Lauren


15 Comments / Post A Comment

summer beers (#6,232)

This answer is really great! One thing I would add is that your insurance company may have a window for all appeals that starts from when they sent you the explanation of benefits and doesn’t depend on when you get a bill from the lab. For example, my insurance has a 180 day limit for appeals. I have been sitting on mine for a month or so and this post reminded me to get on that. Mine is luckily only a difference of $300 from a $600 ambulance bill.

julebsorry (#1,572)

My OB bills my insurance $690 per ultrasound appointment. What my insurance actually pays (their “negotiated rate”) is $90, plus my $20 copay. So, it’s not wildly unlikely that the lab might just accept the $464, since the billed amount from medical companies seems to have very little to do with what actually needs to be paid. In my example, if I didn’t have insurance and received a $690 bill from my OB, I’d be horrified. If they magnanimously offered to give me a 50% discount and only charge me $345, I’d probably feel like I got cut a good break – but meanwhile, my insurance actually only pays $90+$20 for the service, so I’d still be getting ripped off (compared to what my insurance negotiated to pay) even with a 50% discount.

Trilby (#191)

Our health care system is really something, isn’t it? Even when you ask, no one can tell you with any certainty what you’ll be charged for a particular service. It’s like being mugged– you have to open your wallet and they take what they want. Sucks!!!

One of the few things you can kinda control is only using doctors and services in-network, to get the much lower, negotiated fees. Take this as a learning experience and going forward, never accept the “good lab” without asking that crucial question!

I too have learned this the hard way.

dham (#2,271)

They very well might accept the $464!

Recently, I went to the ER after I had a bad fall. I didn’t wind up seeing a doctor–one came into the waiting room and said that if I could stand, I was fine.

I got a an “Explanation of Benefits” billing $1000, of which I owed a $75 co-pay. I paid this.

That same week, I got a bill for $250 from the hospital. I ignored it because I mistakenly assumed it was part of the $1000 my insurance had already paid. When I received notification it had been sent to collections, I called the billing company.

It turns out there are two different billing companies for visiting the ER- the doctor’s and the lobby’s. The former claimed not to have received my insurance info from the latter! They submitted the claim to my insurance, and in the end, my insurance paid $60. Even though I was sent to collections for $215 the same week!

Long story short, don’t do what I did: take care of the bill ASAP, and make sure you pay less than it is for.

Stina (#686)

@dham Way too much information on why you got two bills I’m sure: Most hospitals contract with a “ER physician group” to staff the ER so technically the Docs aren’t employees of the hospital, yet the rest of the staff are and the Hospitals provide the equipment, the lights/heat etc.hence the two different bills. Same with Docs who do a surgery in a hospital and sometimes the anesthesia people are independent contractors as well…

yellowshoes (#4,954)

I’m another learned-the-hard-way person (though it did make me so much insurance-smarter in the long run!). My suggestion for the future: Call your insurance company and ask them which lab processing facilities are in-network. Sometimes doctors may not always know themselves which labs are in-network for which insurance plans — hey, no skin off their back whether you’re billed in or out of network. I’ve found that you’re much more likely to get in-network processing if you’re able to say to them “This NEEDS to go to Quest or Sunrise Labs (or wherever)” rather than just “please keep this in my network”.

Another thing: I bet your doctor will TOTALLY negotiate with you. They’d rather get some money than no money. I once put off paying an $800 small office, single-provider podiatrist bill because my shit insurance only allowed about $40 of it and I couldn’t afford the rest. I finally told the receptionist what’s up, they asked to see the Explanation of Benefits (Mike, I can’t believe you shred them!!), and then cut my bill from $800 to, like, $100.

Also, not quite as relevant but hopefully helpful: If you have a procedure that you expect to receive again, you can look up your CPT Code on the doctor’s bill or the Explanation of Benefits. That code is your key to (some) answers from the insurance company. They’ll usually tell you what their allowed amount is for CPT Codes if you badger them a bit for it. That can go a long way in figuring out costs within the overall totally labyrinth system.

In any case — I sympathize. Good luck!

Trilby (#191)

@yellowshoes It’s hard to call the insurer and get that information while sitting in the exam room in your paper gown. Easier to tell the doctor that you only authorize using a lab that’s in-network.

yellowshoes (#4,954)

@Trilby Agreed! For the future = good knowledge to have in your back pocket. You can call the insurance company any time and get specifics. Then when the paper gowns are on, you already know what to say.

Allison (#4,509)

@yellowshoes ahh the CPT codes. My mother is a certified professional coder who’s worked in medical billing for most of my life. This came in really handy when I had to go out of network (because I lived out of network) for a potentially broken elbow my freshman year of college.

It was amazing to see her look at the bill, know what the codes meant and be able to say “Yeah, they didn’t do an 8 organ system review for your ultimately unbroken elbow.” and call to fight the bill. So make sure they’re billing you for things that actually happened!

yellowshoes (#4,954)

@Allison Right?! Once I discovered the codes it was like a little ray of light in a (still incredibly shadowy & confusing) dark maze. I even get treated differently when I’m on the phone with insurance companies and I drop the CPT lingo on them. That’s so awesome that you have a professional decoder in the family!

skip2mylou (#2,806)

Indeed – sort it out sooner rather than later. We just found out when apply for a mortgage that a medical bill for my husband had incorrectly been coded that he was uninsured. He never received a bill for it and thus didn’t realize the mistake. It went to collections, causing his credit score to drop by nearly 50 points.
Lesson learned on our part to always follow up and to be more rigorous about checking our credit reports.

monteig (#2,100)

I also had a huge bill for lab bloodwork – just over $1,700. Got the first EOB from the insurance company and totally freaked out because it didn’t look like they were covering anything. Then I just waited for a bill from the lab and when it finally arrived, it came out to be around $150 in the end. While I would not ignore a bill from the actual lab, I would also try and stay calm until you get it.

Also, I would much rather my tests went to the “good lab” – scary that there is a distinction!

mediaandpotatoes (#6,402)

I wouldn’t just assume that your doctor has some nefarious deal with the lab. In my experience, that’s pretty rare, and only exists for megalomaniacal doctors with enormous practices. She may have had some bad experiences/questionable results from the lab that does take your insurance… in which case, maybe your cholesterol hasn’t changed as much as you thought?? But yes, do leave a message at her office and maybe she can find yet another lab that does take your insurance for next time.

binfluenza (#6,403)

I’ve had a similar problem with my PCP and it’s driving me up the wall.

I went in for a routine physical two years ago. I asked them to send lab work to Lab A (in network for me), which they confirmed they worked with. The doctor said, “Oh, we always lab work to Lab B for people who use your insurance… they’re in your network.” Turns out they weren’t. It showed up as out of network on my insurance. I called my insurance company, explained the situation, and they chalked it up as a misunderstanding and reimbursed me. But throughout the entire process, my doctor’s office maintained that they were doing nothing wrong and this was the lab they always sent work to for people with my insurance, even after my insurance company called the office and asked them to send work to a different lab. I ignored it after the issue was settled and the bill was paid, thinking it was a misunderstanding.

Then, a year later, I went back for another physical. I brought up the issue again, thinking it wouldn’t hurt to remind them. The doctor then got really angry with me and said, “No, we have an agreement with Lab B. You shouldn’t be getting any bills from them. Lab A is not in your network.” I insisted she send lab work to Lab A. She agreed after I argued with her. The next day, I got an angry message on my phone saying, “We tried to send your work to Lab A, but they said they were out of your network, so we sent it to Lab B instead. We have an agreement with them.”

Sure enough, I just got an out of network bill from them. I don’t even know what to do here – why would a doctor claim to work with a specific lab and then repeatedly refuse to send anything to them? And I doubt my insurance will reimburse me this time because this is the second time this has happened.

Allison (#4,509)

@binfluenza Can you bring them a copy of your insurance companies network list? because wow. And/or call the labs yourself. And by call I mean email so you have statements in writing you can go back to the doctor with.

I don’t know what to do about the bill though.

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