I have insurance - I went to the doctor.
Had lab work done.
The doctor was a network provider.
That was paid as an in-network expense.
BUT
the network provider sent the lab work
to a non-network provider.
Insurance company refuses to pay for the
lab work saying it was my responsiblity to
make sure the doctor sent it to the right
lab!!!!!!!!!!!!

They sent me an appeal form but quite frankly
I dont' know what that is supposed to solve.

Has anyone ever had this problem.

Just went back on the site.

My husband's doctor also did lab work and
sent it to a non-network lab. Insurance site
shows they are not paying for that one either!!!!!

Any suggestions?????

Thanks,
Marie

Well, I can tell you that I've had that happen to me before. Much of it depends on the type of insurance you have. Some insurance companies require that the doctor be responsible for ensuring all services are in network. It totally depends on the contract they have.

I had a situation once where the doctor was in network and he had his own, onsite lab for all laboratory work. This was HIS lab, but his lab did NOT participate with the insurance, but he didn't tell his patients that. I got socked with a huge bill for labwork and I fought the doctor over it. I think he finally reduced the charges, but I still had to pay. I ended up leaving that doctor. It was my opinion that he did it intentionally (participated with insurance to get the patient in, but made up for the low reimbursements by having his lab NOT participate with those same insurances).

My only recommendation would be to try appealing it with the insurance company, then ensure in the future that your doctor uses an in-network lab or find another doctor that will.

Sometimes letting the insurance company know that you didn't know (because doc didn't tell you) and that you will ensure it doesn't happen again MIGHT help. It totally depends on the insurance company. But it would be worth a try.

Thanks for the info. I have an appeal form now from the insurance company.
I'm going to try and fight it. It comes to over $500!
I don't have much faith in the process but I'm giving it a shot.

Best,
Marie

I have heard of that happening more often that you might think. I've also heard of people having emergency surgery in an in-network hospital but, for example, the anesthesiologist on call happened to be out-of-network and so they were billed for those services. It doesn't fair when it's something you have no control over (who would think to check where the dr. is sending the labs?). At any rate, definitely submit the appeal. Claims denies a lot of things upfront, I think with the expectation that people will just pay it without protest. It is worth a shot - perhaps the squeaky wheel will get the oil, you know? Good luck!

If you go to a hospital for an emergency or usually even a non-emergency procedure and they send your lab work to an out of network laboratory, it's usually covered as ancillary, meaning that they apply in-network benefits to it. Meaning that if you have a co-pay/deductible for out of network services but none for in-network services, you then wouldn't have a co-pay or deductible.

However, that doesn't mean that it'll be covered at 100% because usual and customary rates apply. So if the lab charges $500 and the carrier determines U&C is $300, the lab could still bill you for the remaining $200.

If you go to an in-network physician for an office visit, however, and they send your lab work to an out of network laboratory, it's almost never considered ancillary. For starters, almost all PPO contracts state that the in-network doctor is supposed to use every reasonable effort to send your lab work to another in-network laboratory.

Unfortunately, like Madalot said, some doctors don't follow the terms of their contract and deliberately contract exclusive with an out of network lab. This is usually because they have some financial interest in the lab whether legal or not, given the state. These are the types of physicians that usually order far more tests than are needed and end up getting scrutinized by the carriers. Then not only are you responsible for all the extra tests that your carrier may or may not cover, you're also responsible for any U&C differences.

On top of that, they prey on your ignorance because the second issue is that YOU are ultimately responsible for knowing the terms of your policy. You should be asking your doctor which lab he sends his lab work to and if it's not in your network--again which is ultimately your responsibility though many doctor's offices will check out of courtesy--then ask them if they'll send it to one that is. If they won't, it's time to see a new doctor or suck it up and deal with the out of network costs.

It's very dangerous in today's day and age to just assume that your doctor is on the up and up and playing by all the rules. Or that everything they order will be covered by your carrier just because they're a doctor and they ordered it. Know the terms of your contract with your carrier and actively ask your physician pointed questions about who and where your services will be performed.

This is very eye-opening.
I have had managed care for years but never
had a problem having my lab bills paid.
I sent in the appeal form.
The GYN's office says I should not owe the money
so they seem to be on the same page.

I post the results here.

I guess they do hope that people will just
give up and pay. For me it's more the principle
of the thing.

Marie

Cook82. I hope this info is not too late! Definitely file an appeal. Attach a formal letter explaining the situation. Ask your doctor's office if they will write a letter as well. Also, call the lab to see what they can/will do. They should be able, and willing to help (this isn't always the case).

Be sure to read your explanation of benefits closely. Make sure it says that this charge is your responsibility before you pay the lab. Sometimes, the insurance companies will tell the lab that they cannot bill the patient for unauthorized tests.

As for the doctors.......The ones I work for have their own lab for certain specialized tests. Most insurance companies will contract the lab as well as the doctor; it's just a matter of filling out the right forms, dotting the right "i"s and crossing the right "t"s.

Ultimately, it is your responsibility to know if the lab is contracted. My doctor tries to get me to use Quest Labs because it is across the street from his office. Unfortunately, my insurance isn't contracted with Quest, and I have to tell his office workers this every time the doc wants blood work done.

I can't guarantee any of this will work, but good luck.

You're doctors office is who needs to eat the bill. You made sure the doctor you went to was a provider and you gave them your insurance info. it is then their responsiblity to inform you prior to sending lab work if they send it to a nonnetwork lab. If they didn't inform you, you had no way of knowing and the doctors office needs to eat the bill. You will have to take it in to the office and explain the situation be firm but not flat out rude. They will argue and you'll have to argue right back but in the end you should win. I've been there done that!

I had this happen to me when I had a CT scan. Don't pay it, you'll never get your money back. I did the appeal and after a few months it was paid 100%. I have a HMO.

I had a thought. Does anyone know if its' legal to alter or add to the mandatory paper that you sign up when you go to a new doc that says you are responsible for the charges no matter what?

My thought was to sign it but with a disclaimer that you will be responsible only for your insurances' in network doctors, labs and other facilities.

Anyway, haven't been to a doc in years but when the time comes I'd like to not be caught with my britches down!

Just wonder if anyone knows if we have the right to do this or not.

Well, that's the dirty little secret people who have supposedly dedicated their lives to helping others, pledging to the Hippocratic Oath, won't admit:

If you can't pay, they won't help you.

That piece of paper is nothing short of blackmail. If you don't sign it and agree to their terms and sign away all your rights, then they won't treat you. And since this isn't a matter of say not getting a new muffler put on your car, you could die. It's more blatant in the E/R than anywhere when your life is more likely to truly on the line, but since virtually no doctor's office will treat you either unless you sign it, it's not like you have a choice no matter where you go.

This also gives them free reign to bill whatever they want. Your insurance company might catch it and deny it and save themselves a buck, but then the doctor's office will just come after you. You who has virtually no idea about ICD-9s, CPT Codes, revenue codes, which codes bundle into which, etc. Even if you did manage to figure it out...you really can't fight it since you were made to sign that piece of paper giving away all your rights. You are responsible for whatever your insurance company doesn't cover. Period.

While I don't think people should be skipping out on their bills and that physicians/hospitals should have no recourse, that piece of paper has to go. Or be reworded to include a fair appeal process. Not just "We billed $1,000, your insurance paid $200, here's your bill for $800."

My experience with doctors/insurance companies has usually been more positive -- or perhaps I'm just lucky.

I always confirm that the doctor participates with my insurance. In doing so, the doctor has contracted with the insurance to accept their maximum fee for services as payment in full. I then am obligated to pay whatever contracted amount I have with the insurance as my co-pay.

I have always signed that form saying I am responsible for whatever the insurance doesn't pay, but my doctors have always honored THEIR agreement with the insurance company.

When I became seriously ill a few months ago and ended up in the ER, hospitalized and had emergency surgery, I was terrified about what it was going to cost me. I had signed that form as well so I was pretty scared because we all know how much the hospital costs these days.

I came home and read my insurance paperwork to try to figure out what it SHOULD cost me -- and you know what? I received a bill from the hospital for EXACTLY the amount my insurance paperwork said I would have to pay. The hospital ended up writing off more than half their charges and aside from a few $10 bills here and there for various doctors, I didn't end up paying anything more than what my insurance company contract stated.

I think a lot of it depends on your insurance. And there are some doctors/facilities out there that don't participate with insurance companies.