topic Re: Suggestions on dealing with "lab not in network" situation.... in Community Chat

Suggestions on dealing with "lab not in network" situation....

FiddleDeeDee — Thu, 07 Jan 2021 19:34:05 GMT

Though I did not mention it at the time, it was thought that DH had cancer back in November. I will spare you the issues and hoops we went through to finally get him in for a biopsy; it happened the day before Thanksgiving. Due to the locations and issues with not 1 but 2 tumors, the hospital sent it out to the lab considered best with this type of cancer/biopsy, whatever.

He does NOT have cancer.

Bill arrived yesterday for a tad over $2000 marked "lab not in network". Now, the hospital, the docs, the surgery crew all are. Is it the norm for a patient who knows nothing about cancer or the labs to dictate to the specialist and the hospital which lab they must use? Is this something we SHOULD have asked before surgery? Not kidding as this is the first time we've ever had this occur.

In your experience, what is the best way to handle this? Yes, I know to call the insurance company and I will... AFTER hearing from others who have been down this path. It doesn't help that a call to our CS means at LEAST 2 hours on the phone due to not being able to understand what the person is saying. I DREAD having to deal with this company but there it is.

Thank you in advance!

Re: Suggestions on dealing with "lab not in network" situation....

de1rdre — Thu, 07 Jan 2021 19:45:52 GMT

Congress passed surprise medical protection as part to the recent stimulus bill. Unfortunately, these protections do not take effect until 2022. Meanwhile, Google "how to contest surprise medical bills" and you will find some practical advice on how to try to get your bill reduced.

Re: Suggestions on dealing with "lab not in network" situation....

KingstonsMom — Thu, 07 Jan 2021 19:46:34 GMT

@FiddleDeeDee

ALL of our Dr./medical facilities ask what your 'approved Lab Companies ' are according to your insurance on our first visit with them.

It's usually asked on your 'new patient' sign up sheet, if it's an office that you've never used before and then it should remain in your file for future lab work to be sent to.

Re: Suggestions on dealing with "lab not in network" situation....

KingstonsMom — Thu, 07 Jan 2021 19:49:49 GMT

@KingstonsMom wrote:
@FiddleDeeDee

ALL of our Dr./medical facilities ask what your 'approved Lab Companies ' are according to your insurance on our first visit with them.

It's usually asked on your 'new patient' sign up sheet, if it's an office that you've never used before and then it should remain in your file for future lab work to be sent to.

ETA:

If they didn't ask you for your 'approved' lab in accordance with your Insurance Co., then the responsibility is on them.

Re: Suggestions on dealing with "lab not in network" situation....

Nightowlz — Thu, 07 Jan 2021 19:49:58 GMT

Glad to hear your DH does not have cancer.

Don't know if you are talking about regular Ins or Medicare.

Don't know about Medicare.

With our Ins when I had to have surgery I was asking how much am I going to pay? Does Ins cover this, are the doctors in network etc. If they are not telling you I would be asking.

I would not pay the bill until you receive the EOB from your Ins that shows how much they paid & how much you owe.

Re: Suggestions on dealing with "lab not in network" situation....

Nightowlz — Thu, 07 Jan 2021 19:53:42 GMT

@KingstonsMom wrote:
@KingstonsMom wrote:
@FiddleDeeDee

ALL of our Dr./medical facilities ask what your 'approved Lab Companies ' are according to your insurance on our first visit with them.

It's usually asked on your 'new patient' sign up sheet, if it's an office that you've never used before and then it should remain in your file for future lab work to be sent to.

ETA:

If they didn't ask you for your 'approved' lab in accordance with your Insurance Co., then the responsibility is on them.

@KingstonsMom

I don't remember ever being asked what lab we use?

They always send them over to Lab Corp. Maybe it's the only lab in town. I don't even know.

I have been asked what pharmacy do you use?

Re: Suggestions on dealing with "lab not in network" situation....

DrakesMomma — Thu, 07 Jan 2021 20:04:48 GMT

I've done medical billing for 20+ years. Best thing to do is look at the EOB (Explaination of Benefits) from the insurance company before calling them. Make sure what they tell you is what the EOB says. If you are told something different make them explain. If it not explained for you to understand or to your satsification, ask to talk to the person above the rep that answers the phone. If you get a really good rep on the phone ask if they will do a three way call to the lab's billing office. There could have been a mistake made in billing.

If in the end the claim was billed and processed correctly ask for a discount, especially if you can pay the bill in full. Explain that all the other providers for these services are contracted/in network. Start at 50% of the balance due.

Don't give up. Most people do and pay the bill in full.

Re: Suggestions on dealing with "lab not in network" situation....

Mz iMac — Thu, 07 Jan 2021 20:16:23 GMT

"I would not pay the bill until you receive the EOB from your Ins that shows how much they paid & how much you owe."

EOB's also will state why a particular medical provider was NOT paid or partially paid.

I would think if an "in network" hosp refers something to an "out of network" provider, your ins should/must pay.

FWIW.....

When it comes to medical billings (as well as treatment(s) ), YOU have to be YOUR OWN advocate.

Even though my ins covers me 100% I still go over dr bills & the EOB's w/a fine tooth comb. Any discrepancies, I contact my ins co & I let them battle it out w/the medical providers.

Re: Suggestions on dealing with "lab not in network" situation....

KingstonsMom — Thu, 07 Jan 2021 20:19:14 GMT

@FiddleDeeDee

I would contact your insurance company and find out who your preferred lab is with them and if their preferred lab is not available in your area, they HAVE to process the claim as if the lab you used IS in network.

LabCorp is the preferred lab with our insurance, but we've had other medical services that were initially considered 'out of network by our insurance company, but when we called the insurance company informing them that their 'preferred' service was not available in our area, they covered the claim as if it were 'in-network'

Re: Suggestions on dealing with "lab not in network" situation....

FiddleDeeDee — Thu, 07 Jan 2021 20:29:50 GMT

Thank you everyone.

We have not received the bill from the provider; this WAS the EOB we received and that's how we found out.

I read through all the documentation with it and since it was out of network it does not apply to our deductible either. Here's my thing: it's a PPO so we're supposed to go anywhere without issue. We have Lab Corp and Quest...are there others that hospitals use? Nowhere on the hospital in patient paperwork does it state which lab will be used for the work.

Again, this has never happened in all our years with insurance. That said, this is the FIRST time we are not using BCBS but United National. Guess we've learned a huge lesson. Great.

Re: Suggestions on dealing with "lab not in network" situation....

KingstonsMom — Thu, 07 Jan 2021 20:30:04 GMT

@Mz iMac wrote:
"I would not pay the bill until you receive the EOB from your Ins that shows how much they paid & how much you owe."

EOB's also will state why a particular medical provider was NOT paid or partially paid.
I would think if an "in network" hosp refers something to an "out of network" provider, your ins should/must pay.

FWIW.....
When it comes to medical billings (as well as treatment(s) ), YOU have to be YOUR OWN advocate.
Even though my ins covers me 100% I still go over dr bills & the EOB's w/a fine tooth comb. Any discrepancies, I contact my ins co & I let them battle it out w/the medical providers.

@Mz iMac

You know I love ya' girl and 'most' (LOL!) of your posts , but please don't tell me that you're going with the pink type, it's so hard on the eyes for me.

Another poster posts in pink and I just pass her posts right on by, too hard to read!

Re: Suggestions on dealing with "lab not in network" situation....

D Kay — Thu, 07 Jan 2021 20:33:52 GMT

If you can get documentation from your doctor/hospital that this particular lab has expertise with this type of biopsy, your insurance may reconsider.

Re: Suggestions on dealing with "lab not in network" situation....

Mz iMac — Thu, 07 Jan 2021 20:46:16 GMT

@KingstonsMom Is this better?

Re: Suggestions on dealing with "lab not in network" situation....

KingstonsMom — Thu, 07 Jan 2021 20:47:40 GMT

@Mz iMac wrote:
@KingstonsMom Is this better?

Oh yeah, GF!

Re: Suggestions on dealing with "lab not in network" situation....

Love my grandkids — Thu, 07 Jan 2021 21:01:28 GMT

@KingstonsMom I agree. I read NOTHING posted in bright pink!

Re: Suggestions on dealing with "lab not in network" situation....

robbn99 — Fri, 08 Jan 2021 01:55:14 GMT

I just retired from a large national insurance company and worked in the Appeals/Grievances dept for last several years. My suggestion is do not pay until you receive the EOB. First, I would suggest you call the customer service and obtain details why denied. But, once you get the EOB and they deny, there will be an appeal notice with instructions on how to appeal the denial. Usually they require to be in writing and provide an address on how to submit. Some will take faxes, but likely no email. Insurance companies want paper trail. Do a written ltr signed by your husband and explain your circumstances in detail on the provider chose the lab and you had no say where it was sent. And, cancer possibility and all details you included. It will be reviewed by the appropriate area. Make copies of all you send. If they deny again, there will be 2nd appeal likely offered. File appeals until you have exhausted your rights. Likely, they will include notice of your State's Insurance Dept and your right to contact them. You are better off filing the appeal since some State Insurance Depts require you to exhaust your appeal rights first before they will review your case. Good luck, but be diligent in your efforts.

Re: Suggestions on dealing with "lab not in network" situation....

VaBelle35 — Fri, 08 Jan 2021 03:11:05 GMT

This has happened to me a couple of times over the years with lab work through the doctor's office. And when I call the doctor's office they are already on it and have fixed it. In those cases it was usually the difference between Labcorp and Quest or something.

I would start with the provider who submitted the stuff to the lab to see what they say and then go from there.

Re: Suggestions on dealing with "lab not in network" situation....

Lipstickdiva — Fri, 08 Jan 2021 17:26:36 GMT

I have never been asked at any doctor's office what lab(s) is covered by my insurance. They ask who my insurance company is and they take a copy of my card.

Many times if the insurance won't pay any of it, a self-pay discount is given.

Re: Suggestions on dealing with "lab not in network" situation....

Carmie — Fri, 08 Jan 2021 21:33:27 GMT

This is easy. I have over 25 years working for a health insurance company.

Appeal the claim in writing..do not call. Make the first line of your correspondence I am appealing claim #xcxxxxxxx. Don't appeal until you get a denial from your insurance co....wait for the claim #.

You had no choice and did not choose this provider. This type of provider is called a "ghost provider"

Write in your letter that you would have chosen an in network provider, but one was not available and you weren't given a choice. Also, point out that the Hospital and surgeon were in network.

They have 30 days to respond and you will receive a letter in a few days stating they have your appeal letter and are reviewing it.

In about 99.9% of the cases, the claim will be paid. If denied, you can do a second appeal, but I don't think that will be necessary.

Best of luck to you. Oh..one other thing...have your DH sign the letter just in case they need his permission for HIPAA.

Re: Suggestions on dealing with "lab not in network" situation....

Icegoddess — Fri, 08 Jan 2021 21:53:10 GMT

I'm glad your husband doesn't have cancer and I feel your pain although not to that extent. I went through this a couple of years ago for a simple pap smear. I go to an in-network facility and an in-network doctor. I was never asked what lab was the approved lab for my insurance, and, to tell you the truth, I can not even find that info on their website anymore. However, at the time of my labs getting denied I was at least able to find that info on the BCBS website. BCBS is the ONLY linsurance available to me under NObamacare.

I was not allowed to speak with anybody about it, only file a dispute, and I had to call to get the dispute form sent to me and give them the date of service before they would even do that. Of course it was denied.

I at least now know to as that my Pap labs are processed under Quest Diagnostics, but that's assuming they don't change labs which I wouldn't know since they don't put that info on their webite anymore.

I also remember looking all over their website for an approved mammogram center for my area after reading that was a requirement and couldn't find it anywhere, and neither could the Customer Service Rep I called. And even though I did go to an approved facility, I got denied because the doctor who read the mammogram was out of network. At that time I was able to actually speak to someone about how I had no control over who reads the mammograms and she agreed with me and they did pay for it.

Hope you have better luck.