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Honored Contributor
Posts: 19,658
Registered: ‎03-09-2010

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


@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!

You never know how strong you are until being strong is the only choice you have.
Valued Contributor
Posts: 578
Registered: ‎04-20-2010

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

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

Honored Contributor
Posts: 16,280
Registered: ‎07-26-2014

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

@KingstonsMom   Is this better? 

 

 

"Never argue with a fool. Onlookers may not be able to tell the difference."


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Honored Contributor
Posts: 19,658
Registered: ‎03-09-2010

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


@Mz iMac wrote:

@KingstonsMom   Is this better? 

 

 


Oh yeah, GF!

You never know how strong you are until being strong is the only choice you have.
Honored Contributor
Posts: 11,432
Registered: ‎11-24-2013

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

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

Contributor
Posts: 48
Registered: ‎03-31-2019

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

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.  

Honored Contributor
Posts: 17,487
Registered: ‎03-10-2010

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

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. 

===================================
QVC Shopper - 1993

# IAMTEAMWEN
Honored Contributor
Posts: 33,581
Registered: ‎03-10-2010

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

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.

Honored Contributor
Posts: 15,419
Registered: ‎10-25-2010

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

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.

Honored Contributor
Posts: 8,605
Registered: ‎03-19-2010

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

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.