Lab tests not covered during annual physical exam

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aragorn1
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Lab tests not covered during annual physical exam

Post by aragorn1 »

Hi,

I was enrolled in a High Deductible Medical Plan with UHC through my employer in 2021. I'm 36 yo and based in CA. I went for my annual physical exam in December after an insurance rep (who I had called for a different issue) advised me to go for one as it is covered under my plan. I was not able to get an appointment with my PCP and so booked an appointment with a nurse practitioner at the same provider. The provider is in-network with the insurance. The NP did my physical and ordered some lab tests. I did not request any of the tests myself. I just assumed that the tests are part of physical exam for everybody :( . Some of the lab tests were the same as for my last physical in 2019. I was on a PPO plan then and didn't pay anything for the tests. The only thing I told the NP was that I had lost a few pounds this year. To which he asked that it's a matter of concern if I lost them in a short period. I confirmed that it was not in a short time span. I got the lab tests the next day from a lab under the same medical facility in another location.

Fast forward 2 weeks and I got a bill from the hospital that I owe a balance of ~$700 for 3 of the 5 tests. I called my medical insurance helpline and the rep said that some of the tests are not considered as preventative but diagnostic. The tests in question are Metabolic Panel (CPT 80053), TSH (CPT 84443) and Lipid Panel (CPT 80061). I spoke to someone at hospital's billing department who told me to contact the doctor's office to see if they can change the codes of the tests. I'm not sure if they will/can change the codes of the lab tests. I have also contacted my company's benefits team.
Additionally, I noticed today that there is a Negative Plan Discount applied in the claim.

Could some please advice what I should do next ?
Last edited by aragorn1 on Sun Jan 16, 2022 3:09 pm, edited 1 time in total.
runner3081
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Re: Lab tests not covered during annual physical exam

Post by runner3081 »

Yep, that is how it works. Anything non-standard/preventive hits the deductible.
nalor511
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Re: Lab tests not covered during annual physical exam

Post by nalor511 »

This happens to me every year for routine blood work, except it's usually like $80 and not $700
Luckywon
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Re: Lab tests not covered during annual physical exam

Post by Luckywon »

aragorn1 wrote: Sun Jan 16, 2022 1:03 pm The tests in question are Metabolic Panel (CPT 80053), TSH (CPT 84443) and Lipid Panel (CPT 80061).
I am in California and all those tests (and more) were fully covered in my last few preventative screens, with no copay or deductible. Perhaps upon review your insurer will cover them.
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JoeRetire
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Re: Lab tests not covered during annual physical exam

Post by JoeRetire »

aragorn1 wrote: Sun Jan 16, 2022 1:03 pmI spoke to someone at hospital's billing department who told me to contact the doctor's office to see if they can change the codes of the tests.

Could some please advice what I should do next ?
Contact the doctor's office to see if they can change the codes of the tests.

And next time, if you don't want to pay for tests, you'll need to determine if insurance would pay for them beforehand and then decline the tests if not.
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chazas
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Re: Lab tests not covered during annual physical exam

Post by chazas »

I’ve had that kind of billing happen with tests before, whether at my annual physical or not. And don’t get me started on the lipoprotein particle test, which BCBS absolutely refuses to cover even though it’s hardly experimental. It’s only a hundred bucks or so though, so more annoying than anything else, but having that test keeps me healthy in a way that the standard calculated cholesterol tests don’t.

I have a HDHP and I have an expensive maintenance med I’m on, and I soon learned that the manufacturer’s copay coupon completely eats up my deductible in January and February without my having to pay anything. So I don’t do anything that’s at all discretionary until late February, even an annual physical (because of the test problem).

All in all, the incentives built into insurance are completely messed up.
HomeStretch
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Re: Lab tests not covered during annual physical exam

Post by HomeStretch »

$700 seems high even at 100% for the in-network insurance contract rate for the three tests.

Was the hospital lab in-network for your plan?

Does the amount owed of $700 to the lab agree with the patient payment per your insurer’s Explanation of Benefits?
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Re: Lab tests not covered during annual physical exam

Post by 123 »

HomeStretch wrote: Sun Jan 16, 2022 3:04 pm $700 seems high even at 100% for the in-network insurance contract rate for the three tests.
In my experience those kind of charges from a hospital are normal. A couple years ago I checked my employer insurer's website for lab tests I had done (mine were all routine and covered). A routine battery of blood tests had negotiated rates of over $500 if done at a hospital lab yet the negotiated charge was under $100 for that same battery of tests at an independent lab like Quest Diagnostics (which has labs all over in my area). Hospitals just charge a lot more.
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aragorn1
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Re: Lab tests not covered during annual physical exam

Post by aragorn1 »

HomeStretch wrote: Sun Jan 16, 2022 3:04 pm $700 seems high even at 100% for the in-network insurance contract rate for the three tests.

Was the hospital lab in-network for your plan?

Does the amount owed of $700 to the lab agree with the patient payment per your insurer’s Explanation of Benefits?
Yes, the hospital / medical facility (Sutter Health/PAMF) is in network. They charged the following for the tests:
COMPREHENSIVE METABOLIC PANEL - $181 , LIPID PANEL - $230 and TSH - $219
talzara
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Re: Lab tests not covered during annual physical exam

Post by talzara »

aragorn1 wrote: Sun Jan 16, 2022 1:03 pm I called my medical insurance helpline and the rep said that some of the tests are not considered as preventative but diagnostic. The tests in question are Metabolic Panel (CPT 80053), TSH (CPT 84443) and Lipid Panel (CPT 80061).
Luckywon wrote: Sun Jan 16, 2022 2:53 pm I am in California and all those tests (and more) were fully covered in my last few preventative screens, with no copay or deductible. Perhaps upon review your insurer will cover them.
Here are the preventive services that the ACA requires all plans to cover at no copay or deductible: https://www.healthcare.gov/coverage/pre ... -benefits/

Cholesterol screening is covered "for adults of certain ages or at higher risk," but it doesn't say what ages qualify for coverage. The other two tests are not required to be covered. Each insurance plan can decide whether or not to cover them.
HomeStretch
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Re: Lab tests not covered during annual physical exam

Post by HomeStretch »

aragorn1 wrote: Sun Jan 16, 2022 3:43 pm
HomeStretch wrote: Sun Jan 16, 2022 3:04 pm $700 seems high even at 100% for the in-network insurance contract rate for the three tests.

Was the hospital lab in-network for your plan?

Does the amount owed of $700 to the lab agree with the patient payment per your insurer’s Explanation of Benefits?
Yes, the hospital / medical facility (Sutter Health/PAMF) is in network. They charged the following for the tests:
COMPREHENSIVE METABOLIC PANEL - $181 , LIPID PANEL - $230 and TSH - $219
Are those amounts before or after they apply your in-network contract rates? Does the amount billed by the hospital agree with the patient responsibility amount per your insurance EOB?
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Nate79
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Re: Lab tests not covered during annual physical exam

Post by Nate79 »

My understanding is that the lab tests must be coded properly as part of a preventative visit and not diagnosis.
talzara
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Re: Lab tests not covered during annual physical exam

Post by talzara »

Nate79 wrote: Sun Jan 16, 2022 3:57 pm My understanding is that the lab tests must be coded properly as part of a preventative visit and not diagnosis.
A preventive test is still free even if the office visit is diagnostic.

This is the guidance from Compliance Dashboard, a service used by employers to comply with health insurance regulations:
Where a covered preventive health service is billed separately — e.g., lab work for a cholesterol screening conducted during an office visit, if the office visit is not, itself, for preventive health services and the lab work is billed separately — the plan or insurer may impose cost-sharing requirements for the office visit, but cannot impose cost-sharing for the preventive health service.

https://complianceadministrators.com/pp ... uirements/
nalor511
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Re: Lab tests not covered during annual physical exam

Post by nalor511 »

talzara wrote: Sun Jan 16, 2022 4:11 pm
Nate79 wrote: Sun Jan 16, 2022 3:57 pm My understanding is that the lab tests must be coded properly as part of a preventative visit and not diagnosis.
A preventive test is still free even if the office visit is diagnostic.

This is the guidance from Compliance Dashboard, a service used by employers to comply with health insurance regulations:
Where a covered preventive health service is billed separately — e.g., lab work for a cholesterol screening conducted during an office visit, if the office visit is not, itself, for preventive health services and the lab work is billed separately — the plan or insurer may impose cost-sharing requirements for the office visit, but cannot impose cost-sharing for the preventive health service.

https://complianceadministrators.com/pp ... uirements/
These are not by definition preventative tests. I can check my door lock on a regular basis (preventative) or I can check it because I thought I heard something (diagnostic), and it depends on how it's coded... Likely they make more coding things diagnostic
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Re: Lab tests not covered during annual physical exam

Post by mkc »

aragorn1 wrote: Sun Jan 16, 2022 1:03 pm Fast forward 2 weeks and I got a bill from the hospital that I owe a balance of ~$700 for 3 of the 5 tests. I called my medical insurance helpline and the rep said that some of the tests are not considered as preventative but diagnostic.

Additionally, I noticed today that there is a Negative Plan Discount applied in the claim.
#1 Does the hospital's bill show a negotiated rate/insurance payment/insurance submission at all? Do you see a claim submitted to your insurance for these tests when you sign into your insurer's website/have you received an EOB from the insurance company for this claim?

#2 The "Negative Plan Discount" might indicate the hospital didn't have your insurance information and gave you a self-pay discount. That ties into #1 or it could be the hospital's billing department opted to give you their standard self-pay discount for those tests not covered by insurance.
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Re: Lab tests not covered during annual physical exam

Post by Jack FFR1846 »

Did they bill the correct insurance company?

Boy, does that sound like a stupid question, right? We have providers bill the wrong company at least a dozen times a year. Clearly explaining the correct company (our card makes it confusing....insurance company uses another insurance company's network) and sometimes we have no clue. We had an emergency room visit bill an insurance company for a company I worked for 6 years ago, despite having been given the correct, newer insurance company.

As far as dis-allowed tests, I do know that some companies can tell you right then and there that a test isn't covered. I had my labs done last year once by Quest. The person doing the blood draw, before doing it got into the insurance software and it told here that a vitamin D test isn't covered. She said it would cost me $240. I said no.
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eye.surgeon
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Re: Lab tests not covered during annual physical exam

Post by eye.surgeon »

You chose a high deductible medical plan. You just experienced a high deductible. It's really not any more complicated than that. Read up on them. They're a good choice for many people, I have one. I know the first couple medical encounters per year will be basically out of pocket.

A high deductible health plan is kind of like going 100% equities, it's best for most people long term, but you have to have the constitution for it. If one large bill is going to send you into a tailspin, consider a conventional insurance plan next open enrollment.
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AnEngineer
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Re: Lab tests not covered during annual physical exam

Post by AnEngineer »

eye.surgeon wrote: Sun Jan 16, 2022 5:54 pm You chose a high deductible medical plan. You just experienced a high deductible. It's really not any more complicated than that. Read up on them. They're a good choice for many people, I have one. I know the first couple medical encounters per year will be basically out of pocket.

A high deductible health plan is kind of like going 100% equities, it's best for most people long term, but you have to have the constitution for it. If one large bill is going to send you into a tailspin, consider a conventional insurance plan next open enrollment.
But things in the preventative list set up by ACA still have to have be 'free', even on a HDHP, but they can be billed incorrectly resulting in a bill when there shouldn't be.
fortunefavored
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Re: Lab tests not covered during annual physical exam

Post by fortunefavored »

aragorn1 wrote: Sun Jan 16, 2022 3:43 pm
HomeStretch wrote: Sun Jan 16, 2022 3:04 pm $700 seems high even at 100% for the in-network insurance contract rate for the three tests.

Was the hospital lab in-network for your plan?

Does the amount owed of $700 to the lab agree with the patient payment per your insurer’s Explanation of Benefits?
Yes, the hospital / medical facility (Sutter Health/PAMF) is in network. They charged the following for the tests:
COMPREHENSIVE METABOLIC PANEL - $181 , LIPID PANEL - $230 and TSH - $219
JFYI, Sutter is one of, if not THE most expensive health care networks in the bay area. Also some of the highest paid execs.

If you are not on a caddilac care plan PPO, I would look else where.
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Re: Lab tests not covered during annual physical exam

Post by talzara »

nalor511 wrote: Sun Jan 16, 2022 5:29 pm These are not by definition preventative tests. I can check my door lock on a regular basis (preventative) or I can check it because I thought I heard something (diagnostic), and it depends on how it's coded... Likely they make more coding things diagnostic
The ACA requires specific preventive services to be covered with no cost sharing. It does not matter whether or not there is a diagnostic code. It is the service itself that is free.
AnEngineer wrote: Sun Jan 16, 2022 6:22 pm But things in the preventative list set up by ACA still have to have be 'free', even on a HDHP, but they can be billed incorrectly resulting in a bill when there shouldn't be.
The ACA preventive services list includes a lipid panel based on age and risk. The USPSTF recommends screening beginning at age 40, so the OP is too young to qualify based on age. We do not know if the OP qualifies based on risk.

The OP's other two tests are not on the ACA preventive services list, so they are not required to be covered.

Some states may have additional requirements, but Covered California lists the same preventive services as the federal exchange: https://www.coveredca.com/learning-cent ... tive-care/

Of course, an insurance company may provide more coverage than the ACA requirements. If there is additional coverage, it will say so in the policy.
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Re: Lab tests not covered during annual physical exam

Post by AnEngineer »

talzara wrote: Sun Jan 16, 2022 8:01 pm
nalor511 wrote: Sun Jan 16, 2022 5:29 pm These are not by definition preventative tests. I can check my door lock on a regular basis (preventative) or I can check it because I thought I heard something (diagnostic), and it depends on how it's coded... Likely they make more coding things diagnostic
The ACA requires specific preventive services to be covered with no cost sharing. It does not matter whether or not there is a diagnostic code. It is the service itself that is free.
I've had billing issues because things that are supposed to be free were coded incorrectly. I'm not positive whether it was preventative vs diagnostic, but the billing code can matter. After spending enough effort I've usually gotten them fixed.
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Re: Lab tests not covered during annual physical exam

Post by stocknoob4111 »

The codes are wrong - it needs to be coded preventative since that was your case. It can't possibly be diagnostic as you don't have any disease that is being diagnosed. Your current levels were simply being checked to assess your current condition without any symptoms of disease.

I had the same tests as well, Metabolic Panel and Lipid Panel are definitely covered, Lipid panel tests cholesterol, Metabolic Panel checks for diabetes so most certainly covered by ACA. They were covered no cost for me last year.

TSH isn't covered, I had it this year but haven't received a bill from the lab yet but the Aetna cost estimator said in network cost is like $20 so that cost that you're quoted is simply outrageous.
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aragorn1
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Re: Lab tests not covered during annual physical exam

Post by aragorn1 »

stocknoob4111 wrote: Sun Jan 16, 2022 8:15 pm The codes are wrong - it needs to be coded preventative since that was your case. It can't possibly be diagnostic as you don't have any disease that is being diagnosed. Your current levels were simply being checked to assess your current condition without any symptoms of disease.

I had the same tests as well, Metabolic Panel and Lipid Panel are definitely covered, Lipid panel tests cholesterol, Metabolic Panel checks for diabetes so most certainly covered by ACA. They were covered no cost for me last year.

TSH isn't covered, I had it this year but haven't received a bill from the lab yet but the Aetna cost estimator said in network cost is like $20 so that cost that you're quoted is simply outrageous.
Were you also on the UHC high deductible health plan ? Could you please share the codes so that I can discuss with the doctor's office ?
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Re: Lab tests not covered during annual physical exam

Post by aragorn1 »

mkc wrote: Sun Jan 16, 2022 5:30 pm
aragorn1 wrote: Sun Jan 16, 2022 1:03 pm Fast forward 2 weeks and I got a bill from the hospital that I owe a balance of ~$700 for 3 of the 5 tests. I called my medical insurance helpline and the rep said that some of the tests are not considered as preventative but diagnostic.

Additionally, I noticed today that there is a Negative Plan Discount applied in the claim.
#1 Does the hospital's bill show a negotiated rate/insurance payment/insurance submission at all? Do you see a claim submitted to your insurance for these tests when you sign into your insurer's website/have you received an EOB from the insurance company for this claim?

#2 The "Negative Plan Discount" might indicate the hospital didn't have your insurance information and gave you a self-pay discount. That ties into #1 or it could be the hospital's billing department opted to give you their standard self-pay discount for those tests not covered by insurance.
In the hospital's bill's "Payments and Adjustments" section, there is a line item for "United Healthcare ADJ CONTRACTUAL (INS)" for 216.72.
On the insurer's website, for the 3 tests that I have mentioned, the Plan Discounts is -$56.28, Plain Paid $0, Deductible is $686.28 and my Responsibility is $686.28.
The other 2 tests which the insurer paid, the Plan Discounts is $273, Plain Paid $0, Deductible is $0 and my Responsibility is $0.
stocknoob4111
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Re: Lab tests not covered during annual physical exam

Post by stocknoob4111 »

aragorn1 wrote: Sun Jan 16, 2022 8:46 pm Were you also on the UHC high deductible health plan ? Could you please share the codes so that I can discuss with the doctor's office ?
I don't have UHC but my bill was from LabCorp. This time I did my tests at Quest.

It just looks like your contracted rates are a rip off... I have done these tests a la carte ordering from the internet, done at the same labs.. I did 13 labs recently and paid a total of $100 for all, no insurance involved.

I used a company called Ulta Lab tests, highly recommend, I had a very good experience.
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Re: Lab tests not covered during annual physical exam

Post by treadingwater »

Last Dr visit I asked for the lab orders to be written out (had the codes on it) so that a) i could call and ask for the cost. b)decline tests I didn't want c) hand carry to quest which was the least expensive option. All were 100% covered on Aca.
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Re: Lab tests not covered during annual physical exam

Post by Grt2bOutdoors »

stocknoob4111 wrote: Sun Jan 16, 2022 9:01 pm
aragorn1 wrote: Sun Jan 16, 2022 8:46 pm Were you also on the UHC high deductible health plan ? Could you please share the codes so that I can discuss with the doctor's office ?
I don't have UHC but my bill was from LabCorp. This time I did my tests at Quest.

It just looks like your contracted rates are a rip off... I have done these tests a la carte ordering from the internet, done at the same labs.. I did 13 labs recently and paid a total of $100 for all, no insurance involved.

I used a company called Ulta Lab tests, highly recommend, I had a very good experience.
What do you mean you "did these tests a la carte ordering from the internet"? Usually you go to a doctor like the OP is saying, they order tests, you tell them you belong to XYZ lab in network and you insist upon it going to XYZ in network lab, not the hospital lab. Can you describe how you are able to do what you say you did while sitting in the chair having samples taken at the same time?
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stocknoob4111
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Re: Lab tests not covered during annual physical exam

Post by stocknoob4111 »

Grt2bOutdoors wrote: Sun Jan 16, 2022 9:56 pm What do you mean you "did these tests a la carte ordering from the internet"? Usually you go to a doctor like the OP is saying, they order tests, you tell them you belong to XYZ lab in network and you insist upon it going to XYZ in network lab, not the hospital lab. Can you describe how you are able to do what you say you did while sitting in the chair having samples taken at the same time?
You don't need a doctor, I ordered the tests I wanted like I was shopping at amazon.com, they sent a req directly to the lab. I visited the lab got my samples in and got the results - direct from the lab but also from Ulta Lab, infact they have a really nice interface for viewing results. They even make the lab appointment for you... it was brilliant. Pay everything upfront, no surprise costs.

There is no insurance involved so no such thing as in or out network.

Also I don't want a doctor charging me $400 for the privilege of telling me my tests when the tests are self explanatory.. most doctors that I have visited are simply scam artists.

This also avoids the OP problem.. a la carte price for a CBC is $15 not $181
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Re: Lab tests not covered during annual physical exam

Post by CFM300 »

aragorn1 wrote: Sun Jan 16, 2022 1:03 pm Could some please advice what I should do next ?
I think the codes for the tests themselves are the same regardless of the reason the tests are ordered. So it might be that the code for the office visit needs to be changed. I had that happen once.
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Re: Lab tests not covered during annual physical exam

Post by testing321 »

aragorn1 wrote: Sun Jan 16, 2022 1:03 pmFast forward 2 weeks and I got a bill from the hospital that I owe a balance of ~$700 for 3 of the 5 tests. I called my medical insurance helpline and the rep said that some of the tests are not considered as preventative but diagnostic. The tests in question are Metabolic Panel (CPT 80053), TSH (CPT 84443) and Lipid Panel (CPT 80061).
These prices are ridiculous. You can order these tests yourself at requestatest.com for $109 and they will create an order for either Quest or LabCorp.
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Re: Lab tests not covered during annual physical exam

Post by stocknoob4111 »

testing321 wrote: Mon Jan 17, 2022 9:48 amThese prices are ridiculous.
I totally concur, these prices border on extortion. Lipid Panel, Metabolic Panel etc. are some of the most "cookie cutter" tests one can do and are some of the cheapest tests available.
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Re: Lab tests not covered during annual physical exam

Post by aragorn1 »

testing321 wrote: Mon Jan 17, 2022 9:48 am These prices are ridiculous. You can order these tests yourself at requestatest.com for $109 and they will create an order for either Quest or LabCorp.
Thanks for sharing the link. I checked and you are right. The lab tests are much cheaper outside. I was under the impression that all of this is part of an annual physical, so I didn't do my due diligence. My last physical at the same hospital with the same insurer (PPO plan then) was fully covered.

Do you think it will help if I reach out to the CA Department of Insurance ? I'm an immigrant (GC application in progress) and don't want to jeopardize it.
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Re: Lab tests not covered during annual physical exam

Post by testing321 »

aragorn1 wrote: Mon Jan 17, 2022 2:08 pmDo you think it will help if I reach out to the CA Department of Insurance ?
No. I would first make sure you have a EoB for the lab service, and if so call the insurance company and ask if the lab was in network, and if so ask why you don't at least get the in network discount. If the lab is not in network, then the PCP's office screwed up and sent it to the wrong lab. If you don't have a EoB for the lab service, then call the lab and give them your insurance information.
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Re: Lab tests not covered during annual physical exam

Post by FireAway »

eye.surgeon wrote: Sun Jan 16, 2022 5:54 pm You chose a high deductible medical plan. You just experienced a high deductible. It's really not any more complicated than that.
Receiving services that the patient expected to be covered as preventative, without any warning of extra costs; and being overcharged for services, has NOTHING to do with being on a HDHP. HDHP only affects 'who' pays for the first $XXXX of services.
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Re: Lab tests not covered during annual physical exam

Post by FireAway »

treadingwater wrote: Sun Jan 16, 2022 9:24 pm Last Dr visit I asked for the lab orders to be written out (had the codes on it) so that a) i could call and ask for the cost. b)decline tests I didn't want c) hand carry to quest which was the least expensive option. All were 100% covered on Aca.
That's a good idea.
The other thing I plan to start doing is advising every doctor at the beginning of each visit "You do not have my consent to provide any services without my prior authorization, after being advised of the cost for said service". Too many bad experiences with doctors adding fees because you asked a question which took them 30 seconds to answer.
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Re: Lab tests not covered during annual physical exam

Post by Nate79 »

FireAway wrote: Mon Jan 17, 2022 2:56 pm
treadingwater wrote: Sun Jan 16, 2022 9:24 pm Last Dr visit I asked for the lab orders to be written out (had the codes on it) so that a) i could call and ask for the cost. b)decline tests I didn't want c) hand carry to quest which was the least expensive option. All were 100% covered on Aca.
That's a good idea.
The other thing I plan to start doing is advising every doctor at the beginning of each visit "You do not have my consent to provide any services without my prior authorization, after being advised of the cost for said service". Too many bad experiences with doctors adding fees because you asked a question which took them 30 seconds to answer.
Have you actually tried this or is it a theoretical exercise at this point? :shock:
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Re: Lab tests not covered during annual physical exam

Post by nalor511 »

Nate79 wrote: Mon Jan 17, 2022 3:44 pm
FireAway wrote: Mon Jan 17, 2022 2:56 pm
treadingwater wrote: Sun Jan 16, 2022 9:24 pm Last Dr visit I asked for the lab orders to be written out (had the codes on it) so that a) i could call and ask for the cost. b)decline tests I didn't want c) hand carry to quest which was the least expensive option. All were 100% covered on Aca.
That's a good idea.
The other thing I plan to start doing is advising every doctor at the beginning of each visit "You do not have my consent to provide any services without my prior authorization, after being advised of the cost for said service". Too many bad experiences with doctors adding fees because you asked a question which took them 30 seconds to answer.
Have you actually tried this or is it a theoretical exercise at this point? :shock:
Doesn't work. I have in writing telling the doctor "please order annual free preventative blood work" and the Dr ordered whatever they wanted. Insurance said doctor does not have that billing info, and orders what they feel it's necessary. No way to correlate the two. So it goes.
gruesome
Posts: 32
Joined: Tue Oct 30, 2018 12:39 am

Re: Lab tests not covered during annual physical exam

Post by gruesome »

Posting my anecdote because my "unexpected charges for a preventative annual physical while on a High Deductible Insurance Plan" experience seems to have finally been resolved! Good luck to you - there is hope!

April 2021: Preventative annual physical. Blood taken on a 2nd visit (the next day) because they didn't have anyone on duty to take blood when I was there.
June 2021: received two bills: $25 from doctor's office for blood draw, $400 from LabCorp for blood tests.

Asked (through doctor's office web portal) what was up with the charges - it was supposed to be a "fully covered" preventative physical.

Doctor's office said the $25 was because the blood draw was on a separate visit. I replied that they didn't communicate the charge when they asked me to come back for the blood draw. The rep nicely dropped the $25 charge.

For the $400 bill from LabCorp, the doctor's office said to contact my insurance (AETNA).

After about 2 hours of hold music and transfers through AETNA's phone systems, an AETNA rep told me to contact the Doctor's office to have the tests "recoded" as preventative. AETNA couldn't tell me "the right codes" so I felt like I wasn't going to make progress when I went back to Doctor.

Sent request to Doctor's office with the vague request to have blood tests "recoded as preventative." I got a response saying they were going to update the billing and they'd get back to me, but they never did.

September 2021: I got a new bill from LabCorp that had been reduced to $100. I asked the Doctor's web portal why the bill went to $100 (and not $0). I got a response saying they'd investigate and get back to me.

November 2021: Doctor's office emailed me with a request for me to send a picture of the LabCorp bill. I sent it right back and they said they'd get back to me -- never heard anything back.

Today: Put my invoice into LabCorp's portal to find out current charges and it says nothing is due!

I guess patience is a virtue?

Will read this thread to find the right way to make sure a 'fully covered' preventative annual physical is actually "fully covered."
coffeeblack
Posts: 770
Joined: Wed Jun 19, 2019 10:20 am

Re: Lab tests not covered during annual physical exam

Post by coffeeblack »

aragorn1 wrote: Sun Jan 16, 2022 3:43 pm
HomeStretch wrote: Sun Jan 16, 2022 3:04 pm $700 seems high even at 100% for the in-network insurance contract rate for the three tests.

Was the hospital lab in-network for your plan?

Does the amount owed of $700 to the lab agree with the patient payment per your insurer’s Explanation of Benefits?
Yes, the hospital / medical facility (Sutter Health/PAMF) is in network. They charged the following for the tests:
COMPREHENSIVE METABOLIC PANEL - $181 , LIPID PANEL - $230 and TSH - $219
Next time ask your insurance if you can go to a quest lab and pay for it yourself and then send them the receipt. Get the lab sheet from your doctor and then go get the labs. It will require more footwork but will save you money. For example a comprehensive panel cost around 50 bucks on Quest. You can check their prices online at quest.com. I just checked and labcorp has some thing similar.
me112964
Posts: 67
Joined: Wed Jan 13, 2016 10:12 am

Re: Lab tests not covered during annual physical exam

Post by me112964 »

Insider tips
1. Never get labs at a hospital. You are paying for brick and mortar as well as a cadre of administrators, staff etc. Get your labs at a free standing facility. I have used an outfit called Any Lab Test which uses lab corp. My labs CBC, CMP, Lipids and PSA bout 179$. In the hospital, >500$.

2. Use your HSA or FSA to pay that bill. If you are a low utilizer of medical services, ie fairly healthy, you will almost never meet the average deductible for most insurances.

3. Know what labs are needed for you age group preventativeLy. I have often seen young providers and physician extenders order way more tests than is necessary? More is not always better and often leads to additional unnecessary tests and costa.

4. Live a healthy lifestyle. The less you depend on the medical system the more you will have for your retirement and the you will be able to enjoy that time as well. Plant based dieting has been shown to extend lifespans considerably and is associated with fewer overall hospitalizations. The average couple will spend about 280000$ after age 65 for healthcare. That is a 14000$/yr vacation budget for 20 years. Not bad.
ee22bee
Posts: 119
Joined: Mon Jan 01, 2018 11:24 am

Re: Lab tests not covered during annual physical exam

Post by ee22bee »

aragorn1 wrote: Sun Jan 16, 2022 1:03 pm ...
I spoke to someone at hospital's billing department who told me to contact the doctor's office to see if they can change the codes of the tests. I'm not sure if they will/can change the codes of the lab tests. I have also contacted my company's benefits team.
...
Just as one more data point: I had also received an unexpected charge for a preventive blood panel. It was eventually resolved by the doctor's office.

The unexpected charge in my case was "80050 General Health Panel", which apparently is a combo code for various preventive blood tests (CBC, Metabolic, TSH). This had always been covered as preventive by my prior plans, including employers and a marketplace high-deductible health plan. But to my surprise, the HDHP I was on in 2020 (a different insurer) did not cover this as preventive. When I contacted them, they pointed me to documentation that specifically stated that this General Health Panel was not covered. I then contacted the doctor's office to see if they can resubmit using individual codes instead. They responded a few days later, said "it's been taken care of". I never saw any new EOB on the insurer site, so I think the doctor's office just waived it.

Good luck, OP. Hope your doctor's office can either recode your line items or waive the balance for you!
loveeatingpizza
Posts: 84
Joined: Mon Jan 13, 2020 9:41 pm

Re: Lab tests not covered during annual physical exam

Post by loveeatingpizza »

Sutter Health Pamf is very expensive, visits are often $300 to $500. Good advice from others about not using their labs and taking it to quest or others.
sschoe2
Posts: 792
Joined: Fri Feb 24, 2017 3:42 pm

Re: Lab tests not covered during annual physical exam

Post by sschoe2 »

I am very interested in this topic. At my previous company we had a phlebotomist draw blood every year and do a full metabolic workup for free as a part of our insurance program (we got a discount for doing so). I have always had a Blue Cross PPO. The new company doesn't do this but I still have a Blue Cross PPO. I haven't been to a Dr. in 20 years (except for hernia surgery in 2017). I am afraid to deal with all the billing games and price gouging.

I'm afraid if I go to the Dr. I will get charged a new patient consult visit fee and then they will send out the labs and they won't get covered, or the Dr. will call with the results and then charge a fee for that. I heard one guy says he dodges calls from his Dr. and gets the results online to avoid this....
Topic Author
aragorn1
Posts: 82
Joined: Sun Jan 16, 2022 12:46 pm

Re: Lab tests not covered during annual physical exam

Post by aragorn1 »

Thanks for everyone who replied to me. I wanted to give an update - UHC reprocessed the claim (for all the lab tests) as a one-time exception for me. I worked with my employer benefits' rep who coordinated with the UHC Advocate on my behalf. It required a couple of exchanges back and forth for a couple of months. I was getting worried the medical provider would send the amount owed to collections and screw my credit score. Thankfully worked out in the end. I was fortunate to get off the hook this time. Need to be careful when I go for for the annual physical this year :wink:
richard.h.gao
Posts: 340
Joined: Tue Jan 18, 2022 11:34 am

Re: Lab tests not covered during annual physical exam

Post by richard.h.gao »

aragorn1 wrote: Sun Jan 16, 2022 3:43 pm Yes, the hospital / medical facility (Sutter Health/PAMF) is in network.
If it's in-network they should charge you the negotiated rate, which is a small fraction of the made up amount, even if it's not covered.
Rex66
Posts: 2954
Joined: Tue Aug 04, 2020 5:13 pm

Re: Lab tests not covered during annual physical exam

Post by Rex66 »

Nate79 wrote: Mon Jan 17, 2022 3:44 pm
FireAway wrote: Mon Jan 17, 2022 2:56 pm
treadingwater wrote: Sun Jan 16, 2022 9:24 pm Last Dr visit I asked for the lab orders to be written out (had the codes on it) so that a) i could call and ask for the cost. b)decline tests I didn't want c) hand carry to quest which was the least expensive option. All were 100% covered on Aca.
That's a good idea.
The other thing I plan to start doing is advising every doctor at the beginning of each visit "You do not have my consent to provide any services without my prior authorization, after being advised of the cost for said service". Too many bad experiences with doctors adding fees because you asked a question which took them 30 seconds to answer.
Have you actually tried this or is it a theoretical exercise at this point? :shock:
Very few doctors willing to deal with that. I wouldn’t. If someone wants to know the costs then I ask our billing to inquire. Of note the insurance company is not obligated even if they approve. They can change their mind after the fact. I also tell the person to call their insurance company. If that’s not good enough then they need a different doctor. This is of course for non urgent things.
123
Posts: 10415
Joined: Fri Oct 12, 2012 3:55 pm

Re: Lab tests not covered during annual physical exam

Post by 123 »

A few years back I was in an PPO health plan and had to get lab tests. By checking the insurer's online estimated charges I saw that if I had the tests done at a very convenient hospital lab the cost would be over $500 but if I went to one of those Quest or LabCorp labs the cost would be less than $100. If I had to pay on my own dime I would go the inexpensive route but in my case the insurance would cover it so convenience won out.
The closest helping hand is at the end of your own arm.
evcsfan
Posts: 42
Joined: Mon Feb 07, 2022 1:03 pm

Re: Lab tests not covered during annual physical exam

Post by evcsfan »

fortunefavored wrote: Sun Jan 16, 2022 7:09 pm
JFYI, Sutter is one of, if not THE most expensive health care networks in the bay area. Also some of the highest paid execs.

If you are not on a caddilac care plan PPO, I would look else where.
And they have been known for price-gouging:
https://www.courthousenews.com/sutter-h ... rust-suit/
https://www.healthcaredive.com/news/jur ... th/618554/
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