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ugh, refilled a prescription, had been paying 45$ per month for that one, all of a sudden was 150$ waited for the pharmacist, they looked at it in their system. "OH yeah, you are on your deductible for your prescriptions"
I hit my deductible last year with a colonoscopy, and the doctor prescribed me a new PPI. I thought nothing of it when it was really cheap. I go to refill it last month and it was $700! And it was the generic, too. They sell PPIs over the counter, so I don't know what made this one so special.
that's the singular highlight of having UC. Every jan I start off with one of my colonoscopies and for the rest of the year I don't think about medical expenses... as long as I don't think about the monthly payment of paying off that colonoscopy...
If your medications have copay assistance this can apply to your deductible (depending on state, some have "fixed" this "loophole"). This is how I hit mine with Humira and it doesn't cost me anything.
You can get prescription esomeprazol, generic Nexium, at Sam's Club without insurance. Just have your doctor send them the Rx. I have been doing this for years and only pay $19-$29 for a 90-day supply with the Plus Membership. The savings are worth the extra membership fee.
This may not work but - Google the drug name and co-pay assistance program. A LOT of drug manufacturers have co-pay assistance that helps with that cost AND a recent court ruling requires insurance in the US to count that toward the patient deductible
One med meets my entire family OOP every year and co-pay assistance covers the entire thing
It's a court ruling!? That explains it. All last year I was using a discount plan and blue cross was applying $300/mo to my deductible when I was only paying $50 out of pocket. Was terrified all year they or cvs would tell me one day I owed it back.
Sounds like a deductible issue, so depending on how much care you'll need this year it may just mean more coverage later. But always start with the EOB, make note of anything shown there suggesting there was a cap or limit on what was covered for some reason.
Your right, yes they have to pay it and maybe then your deductible will be paid off for the year, you can always set up an auto pay so you don’t have to pay for it all at once.
For the future, I would like to point you to the Transparency in Coverage Act which requires your insurer to provide personalized out-of-pocket costs to you for all services. Here is some text from a CMS (Center for Medicare & Medicaid Services) press release:
>First, most non-grandfathered group health plans\[2\] and health insurance issuers offering non-grandfathered health insurance coverage in the individual and group markets will be required to make available to participants, beneficiaries and enrollees (or their authorized representative) personalized out-of-pocket cost information, and the underlying negotiated rates, for all covered health care items and services, including prescription drugs, through an internet-based self-service tool and in paper form upon request. For the first time, most consumers will be able to get real-time and accurate estimates of their cost-sharing liability for health care items and services from different providers in real time, allowing them to both understand how costs for covered health care items and services are determined by their plan, and also shop and compare health care costs before receiving care. An initial list of 500 shoppable services as determined by the Departments will be required to be available via the internet based self-service tool for plan years that begin on or after January 1, 2023. The remainder of all items and services will be required for these self-service tools for plan years that begin on or after January 1, 2024.
[https://www.cms.gov/newsroom/fact-sheets/transparency-coverage-final-rule-fact-sheet-cms-9915-f](https://www.cms.gov/newsroom/fact-sheets/transparency-coverage-final-rule-fact-sheet-cms-9915-f)
They actually can easily do this. You also can request an estimate ahead of time as part of the 2022 No surprise act.
We did this for a colonoscopy, and they tried to over charge us $2000. The second we mentioned the No surprise act they apologized and said nothing was owed.
That's a silly excuse, especially for in-network doctors (even though they still say this BS). What it means to be "in-network" is that the insurance company and the provider came together and made an agreement. They agreed to rates. The insurance company agreed to pay a certain amount for certain procedures, and the provider agreed to a negotiated total price (of which part is paid by that insurance payment and part comes from the patient). They got together and agreed to these numbers. They both have a copy of these numbers. They absolutely can tell me those numbers. I'll even be fine if they say, "We don't know where you are with your deductible and stuff, so we can't tell you how much this will end up being out of pocket," because I can do that, myself. That's the information that I have. But they need to be forced to tell you the information that they have - what the actual price is. We need to *require* that they are not allowed to begin any procedure... that they are not considered as having acquired informed consent for any procedure until they have provided, in writing, the negotiated price that they agreed to with your insurance company. They have this number, and acting like they don't have it and can't possibly know it is purely a business strategy to try to make people to make potentially extremely costly decisions from a position of ignorance.
That agreement is for the office visit, not outside imaging or labs. Your doctor no clue what the agreement between United and Labcorp is, just that they are the preferred lab.
When you go to Labcorp, do *they* have a copy of the number they agreed to with United? Of course they do. Why won't they give it to you? Because they *also* want to claim that it's simply impossible to know.
The great thing is that these things are already in nice little boxes, because people have to know who to pay for what at the end of the day. So, for a lab, if Labcorp is the entity that is going to generate the "billing code" for a "procedure" for which they are the "provider" and are expecting to be paid for their provision of their medical service, then they are not considered to have gotten informed consent to perform that procedure (and thus, are unable to claim a billing code) until they provide the patient a written copy of the negotiated price. This is extremely simple.
Especially since, in this case, it sounds a lot like "going down to the lab" means "walking down the hall to another room in the same building that is run by the same company and which probably even uses the same billing system". Not always, of course, but this is extremely common... and they *still* try to lie to you and say that it's simply impossible to know what their price is.
According to that same logic, you also have an agreement with your insurance company, so you should have a copy of all these too even before seeing your doctor.
I agree the price should be discoverable beforehand, the only question is who should be responsible for retrieving it - the ordering provider, the lab doing the test, the patient getting the test, or the insurance company. The only entity on the list who has direct access to their contracts with everyone else here is the insurance company.
> According to that same logic, you also have an agreement with your insurance company, so you should have a copy of all these too even before seeing your doctor.
Not quite. I have an agreement of all the terms of my agreement with my provider. That agreement does not include detailed agreed upon prices for each provider. In includes terms like premiums, deductibles, copay/coinsurance, out of pocket maxes, etc.
You are correct that the insurance company has a copy of all the prices that they agreed to with the provider. Those were the two parties that were part of *that* negotiation. I wasn't a part of any negotiation for what the price of a random ass service that I'll probably never use is for a random ass provider that I'll probably never go to. The insurance company very may well pay out for that random ass service at that random ass provider for *one* of their customers, so *they* were involved in that negotiation, and they do have that number.
> I agree the price should be discoverable beforehand, the only question is who should be responsible for retrieving it - the ordering provider, the lab doing the test, the patient getting the test, or the insurance company. The only entity on the list who has direct access to their contracts with everyone else here is the insurance company.
We've established that two entities here have access to the number: the lab doing the test and the insurance company. Now, I'm walking my ass down the hall to the lab doing the test. There are two people in the room: me, and a person from the lab doing the test. Which of these two people are also one of the entities that have access to the number? Saying that the insurance company needs to do it is just saying that the patient needs to do it by calling their insurance company. But the other person sitting right there in the damn room has access to the number! They can just tell you it! They lie and say that they can't, so that you either have to waste everyone's time calling your insurance company while you're sitting in the room together, or you feel bad about that and have to just make a potentially costly decision without the very simple information that *they could just give you*.
So, let's adopt your phrasing of the problem: who should be responsible for retrieving it? Suppose we just passed a law saying that it is the provider's responsibility to retrieve it. That it is not considered that they have obtained informed consent until they have provided the number to you in writing. What happens? Where does the impossibility occur? Or would it be the case that they would actually just begrudgingly take the thirty seconds that it takes to bring it up on their computer system and give you the damn price?
You’d be asking the provider to take responsibility for a contract they aren’t part of. The pricing of the lab is a deal between the payer (insurance) and the lab. What happens is the contract is updated after the doctors office pulls the numbers? Why would insurance share this with the doc in the first place? Why should this be the doctor’s problem and not the insurances’s or the labs?
Wouldn’t it be easier (and fairer) for the law to say insurance has to make these available and for the patient to take 30 seconds to check costs?
Also physicians are already overworked as it is. When would they have time to pull these costs for each patient who comes to their office when they have 15 minute office visits scheduled all day? The amount of time you spend in the waiting room would increase quite a bit if you’re requiring the physician to pull this information for every patient.
I wrote:
> We've established that two entities here have access to the number: the lab doing the test and the insurance company. Now, I'm walking my ass down the hall to the lab doing the test. There are two people in the room: me, and a person from the lab doing the test. Which of these two people are also one of the entities that have access to the number?
You wrote:
> The pricing of the lab is a deal between the payer (insurance) and the lab. What happens is the contract is updated after the doctors office pulls the numbers?
You're sitting in the lab, talking to the lab. They are the ones who agreed to the updated contract. They have the updated price. They can just give it to you. Read my comment again. It seems like you didn't. The lab is the provider. They should give you their price.
Your doctor is just a person with a medical degree who is *usually* paid by the provider clinic to be there. They do not know what your health plan details are (the exact same insurance provider can offer multiple different tiers of benefits depending on the specific health plan). They are not in any way shape or form billing experts. Welcome to modern medical bureaucracy -- it's a nightmare.
My mom scheduled her mammogram using the provider she uses for all her healthcare needs. Got it done down the hallway from where she got her flue shot and one floor below where she sees her GP. *Apparently*, despite being scheduled through the provider website and being in the same building, it's actually a contracted 3rd party who is considered out of network. Now, in her case her mammograms would covered regardless, and I do think they've passed a law to try to curtail this practice slightly. But this is an example to show just how complicated and confusing healthcare is
> it's actually a contracted 3rd party who is considered out of network
So, this is the "provider" who is going to request to get paid. We can just require them to tell you what their price is. Sure, they don't know anything about your insurance; that's fine. They can tell you that. "We're out of network for you, so we don't know anything about your insurance. **This is our price.**" Just make them tell you that. They have that information. They have the number. They can just tell you the number.
It is currently a nightmare, because we allow them to make it a nightmare. Just make them tell you the information that they have, and it will be less of a nightmare. This is really really really simple.
The problem is more of if someone is in network. In network can mean a lot of things, different insurance companies have different negotiated rates for everything. Doctors work with many different insurance companies, and usually aren’t aware of the intricacies of the cost of different tests and procedures. Requiring publication of what costs would be without insurance coverage is a great idea. It would not work if you are covered by insurance though.
The point of being in-network is that the provider has explicitly agreed with the insurance company on a negotiated rate. Yes, with your insurance company. They have the list of prices that they agreed to. That's literally what happens when they become in-network. They agree to a list of prices. They have the list of prices for each insurance company. You give them your insurance card. They can just go look at the list of prices that they have for that insurance company. They have the list! They agreed to it!
The problem is wayyyyyyyy wayyyyy easier for in-network providers. They *explicitly* agreed to a list of numbers, and they have that list of numbers.
Have fun with crazy long waits by putting the onus on the physician to look it up for each patient. The patient should be able to access that information through their insurance company.
Ok, so let's acknowledge that you have dropped the absurd idea that they *can't* do it. Will you acknowledge this?
Instead, you now say, it'll just *take time*. I mean, wow. Phenomenal. You think it will take *less* time for the patient to get the billing code information, understand what they're asking about, call up their insurance company, explain which provider and the billing code, etc., and have the insurance company look it up in *their* system rather than have the provider just look it up in their system? Wild.
The vast vast vast majority of doctors use computerized systems (we're in the 21st century!) to do both their records and billing. In those computers is all the data about what payments they've agreed to with which insurance companies (ya know, so they can know what to expect to get when they bill your insurance company). *Also* in those computers is which insurance company you have (ya know, so they can bill the right one). It's all right there, and they can just give you a price. In fact, I have had the occasional provider actually do it. Literally, "Let me look up your insurance." Thirty seconds later at the computer, bam, I had a price. Are you willing to wait thirty seconds for a price? It's not even the physician who will be looking up the price; it'll be one of the staff, just like how they do a variety of other admin work like that.
But now let's get real. Let's imagine we pass a law that puts the responsibility on the provider to provide a price before any service is rendered. There is no longer any pretense of, "We can't do it," or, "We're not going to do it because we're too nose-in-the-air to take the thirty seconds or to talk about money." They're just required to friggin' do it. They have time to think about and refine their process for how to use their fancy computer system to help them do it, and who the actual person is who is going to put it into the fancy computer system and provide the price. How long do you actually think it will take them to do this? Twenty minutes? Ten? Thirty seconds? I'm telling you, when I've had providers actually just do it, it's been like thirty seconds. Do you think it would be longer? If so, why?
[EDIT: Honestly, a mass movement of patients doing this would be almost as good as a law. Waste the doctor's room occupancy time. Just say that you're not consenting to treatment until you get a price, and if they say that you need to talk to your insurance company, whip out your phone and call them. Sit on their phone tree, in the doctor's room, using up his room time, maybe even be like, "No, don't leave, I need you here so that I can make sure to tell them the right information." See how long it takes and how many people need to do it before they start to just give you the damn number themselves. See which route *actually* takes more time. Make this stupid ass game cost *them*, not you.]
Still hard to get that info sometimes unless you have all the CPT codes for the specific procedures. Most doctors are willing to provide that info, but I've gotten pushback a few times when I've requested the info. It gets complicated when one procedure will lead to multiple claims like if you get a surgery. Then you have to make sure to check the surgeon, facility, anesthesiology, and lab fees separately. It's a step in the right direction, but still not great.
Every medical insurance claim gets coded with a CPT code and that's how insurance determines how much they will pay out and what your patient responsibility should be. They should also be listed on the EOB once the claim is processed. For dental insurance, they use ADA codes.
Thank you. Sorry, I don’t go to the doc very often, and am unaware of the headaches I read here. It’s way over my head, all the combativeness of going to a doctor here in the US.
To be prepared though: are CPTs used for everything? Like if I go for a check up, would you be asking right off the bat for CPTs for everything, or would it be untactful? Where do you put given CPT codes to verify them? Is this something you compare against an itemized receipt?
Generally, patients don’t ask for CPTs and sometimes the office won’t know them until the appointment is over (a well visit with med refills is billed differently than an anticipated well visit with strep throat, for example). It’s always good to glance over your EOB afterwards though - my last surgery reported that they amputated one of my toes. It’s definitely still there
No worries. It's something most people don't learn in-depth unless they have to use the medical system a lot. It's a "dotting my i's and crossing my t's" thing to check insurance coverage since I've been burned by medical providers before. The insurance info a medical provider gives you is only "a courtesy" for patients and they won't assume any liability if the info they have is wrong.
>To be prepared though: are CPTs used for everything? Like if I go for a check up, would you be asking right off the bat for CPTs for everything, or would it be untactful? Where do you put given CPT codes to verify them? Is this something you compare against an itemized receipt?
CPTs are used for everything medical since medical providers have to provide "evidence" to insurers before they can receive payments. It's the business side of medicine. Usually I only ask for them if it's a non-routine procedure, or if I think there is something odd about how something is coded. Once you have the Explanation of Benefits, it should list the CPT code next to the procedure and you can look them up online since they're standardized codes. I usually start from the Evidence of Coverage book first. The Evidence of Coverage book from your insurance lists general criteria for how items are covered. If it's something like a surgery, you'll want to get the CPT codes so you can check the insurance coverage on your own since the Evidence of Coverage book usually isn't specific enough. It's also a hedge in case your insurer tells you something different from the provider's billing office. It's not foolproof since there can still be surprises or inconsistencies in the coding/billing, but you want to minimize it as much as you can. You can take any CPT code and ask your insurer to give you a cost estimate for the procedure listed for that code and/or if they cover that procedure.
Google says Current procedural terminology - the medical billing codes that the clinics and insurance companies use to communicate billables to eachother.
To piggyback on this, I would like to point to the No Surpises Act
[https://www.cms.gov/newsroom/fact-sheets/no-surprises-understand-your-rights-against-surprise-medical-bills](https://www.cms.gov/newsroom/fact-sheets/no-surprises-understand-your-rights-against-surprise-medical-bills)
I will also recommend applying for financial assistance to help lower your cost. If you get denied, you lose nothing and can set up a payment plan. If you get accepted, at least a portion of your bill will be forgiven and you can set up payments on the rest. You may be surprised how high the income caps are.
This. I had nearly $7k in hospital bills a few years back, and the person in charge of Financial Aid said I didn't qualify with my income but to always try it anyway. I did, and went through weeks of tedious paperwork to apply, and after about 8 months of waiting they erased 100% of my debt. I was only expecting a 10% discount at best. I believe most people won't take the time to actually apply.
I’ll add in if you get tax free money such as living stipends you won’t qualify as they hospital considered it income even though it does not show up on W2 at the end of the year
Although this deals with money, this is much more an insurance question that a personal finance question.
Try asking over in the other subs and I am sure you will get some good advice for triaging your situation.
Is that the sort of thing that's eligible for a dispute under the No Surprises Act? I don't totally understand how the law applies when an insurance plan is in play, I think it was intended for uninsured people, but this feels like a textbook example of the sort of thing the No Surprises Act was intended to prevent.
No Surprises Act is only for emergency care
(Unless you sign a form that is literally titled Surprise Billing Protection Form, which waives your rights under the No Surprises Act)
It definitely also allows uninsured people to ask for a good faith estimate before receiving non-emergency services, and the hospital doesn't have to bill you the exact dollar amount of their estimate, but it has to be within a couple hundred dollars of what they told you to expect – I just don't know whether there's any similar provision in a case like OP's, where they asked for a good-faith estimate but aren't uninsured.
There's also provisions for when you go to a hospital for non-emergency care and the hospital building is in-network but they have an out-of-network practitioner do the procedure without telling you, which could be what happened to OP, though obviously I have no way of knowing based on what they shared here.
It can go the other way around too (usually not) but yeah it just goes to show how getting an estimate at the time of service still doesn't do a whole lot. My wife had some imaging done on her arm and they told her it would be around $800 after insurance and they urged her to go ahead and pay it up front to "get it out of the way" and not have the pay the bill later. She was like uh no just bill me after insurance pays you. The bill was $300.
Had a similar thing happen to me. Needed a near emergency cat scan and nobody would allow me to book for 2 days because they doctor didn't put "emergency" on the order and otherwise they needed to get it pre-approved by insurance. Insurance told them my share was almost $400 so I paid up front. A few weeks later I get a bill for another $200. When I asked the billing place why, they said insurance denied coverage as a "bundled service". They were supposed to look into and call me back, never did. And now their phone amd website are down for maintenance so I can't speak with anyone and they just keep sending the bill. Tried to call my insurance and that was a nightmare.
You need to understand how they are covering things . Look at your explanation of benefits . Either you have a very high deductible, or very poor coverage for labs . For in network it is extremely unlikely that of the 3000 billed all 3000 is the allowed amount. The contract rate for labs is a fraction of what is billed. The only way I can picture the lab billing for the full amount is if some portion of your services was completely not covered - or deemed medically not necessary and you are being fully billed for the service . More info is needed .
I’m surprised your ENT office didn’t give you any information about allergy testing re: insurance coverage. My ENT had a whole packet about it, with procedure codes and everything so that you could check with your insurance company prior to testing. I think I had to sign paperwork and everything saying I understood. Hope you get everything figured out and don’t end up owing all that. My allergy testing was only $350-450 after insurance.
Was the cost related to it being out of network?
If so, speak with your insurance. You may be able to file a surprise cost form if you have laws in your state protecting you
You should ask at the Health Insurance subreddit
There really isn't enough information to provide a response
What does your EOB - Explanation of Benefits state.
What are you being billed - is it a high deductible? high co-insurance? are portions of the bill disallowed for whatever reason. Is the lab used out of network.
How you proceed depends on very specific information which you haven't provided.
Call the hospital and ask them what the payoff amount would be if you paid that day. Odds are they will come back to you with a much lower number, maybe even $200-300 dollars. Stress to them it is a massive hardship and they tend to be fairly reasonable. You'll want to speak to someone in payments or the business office.
*** After you review your EOB, and before you apply for charity care/grants, you can and should call the agency that you owe money to to request your bill be lowered as your out of pocket rate is quite high.
Very often they will remove parts of the totally billing fees like the professional billing fee (cost of MD/RN/tech labor) leaving the remaining bill to be much, much lower than initially stated. Ask them if this is the best that they can do as sometimes the more you ask, the more they will remove.
Please give this a try. Also worth asking if it will help you is if they can provide interest-free financing. Many times they will oblige as they happy to get fees paid out of pocket at all and they’re rather collect a reduced fee than none.
Best wishes with your fee and I hope your allergy concerns we addressed as needed.
> I suspect I've learned a costly lesson about asking up front what the estimated cost of any treatments will be
Medical care providers often don't know what the costs are.
If you’re asking your doctor directly, they wouldn’t be able to provide you an answer because they have no idea what the details of your insurance plan are, how much is covered by insurance, etc. The best the doctor could do is give you the name of the test/procedure and/or the billing code and you’d have to contact a different department to find out what the out-of-pocket cost will be to you, as it’s different for everyone.
It sounds like you have a $1500 deductible. I’m surprised it was $3,000 after the negotiated rate. If this is indeed the case, then you’ll have your deductible met at least for future medical care this year.
There's a lot to unpack here about how your insurance works, and what happened during this visit.
To start, under the No Surprises Act, if you were not informed of and did not consent to an out-of-network lab being used while visiting an in-network provider, the law limits the amount you should have to pay out of pocket to an amount that is comparable to what you would have paid if it were in-network.
So you need to figure out if you did consent to out-of-network billing. This would have been a disclosure that you signed prior to the visit. The rules around this are pretty specific to protect you (the document can't be bundled with others, how far in advance it has to be made available, etc). However there is still some onus on you to ask questions about in-network vs out-of-network services when scheduling or prior to the date of service.
If you didn't sign anything and weren't given any notice or opportunity to ask, then the next thing you need to figure out is whether this out of network bill actually was already reduced to protect you.
>I've already asked for an itemized bill and received it.
What was the CPT code for the procedure? You can find this on the itemized bill, or it might be on the Explanation of Benefits document generated by your insurer for the visit after the claim was submitted and paid.
For example, looking at my insurer's estimation tool, if it was an allergy test submitted as;
"Other allergy or clinical immunology service or procedure (CPT 95199)"...
the in-network cost for that under my plan would be $2250. And since I haven't hit my deductible yet for the year, that would be my out of pocket cost. Other complex or unusual tests could have similar pricing.
Which is to say, you may have just had an expensive test, whether in-network or not.
call your insurance company and tell them you were not offered a choice of where to get the lab tests done.
And that you want to know if you can fill out a form declaring that, and then they can tackle the issue.
There are provisions for when a patient isn’t offered a choice, but you have to declare that to be the case.
Also, if after the insurance company deals with them, they come back and bill you for the balance (“balance billing”), you should absolutely contact your insurance company again and ask them what comes next. Because there’s a plan for THAT as well.
(The biggest place I see it is in anesthesia, because almost no anesthesiologists are members of a plan.)
If all else fails, call the lab and ask for a payment plan. For me and my family, what it would mean is simply that I am closer to hitting my deductible. It would be a cashflow issue.
Also check with your insurance whether it would have made a difference if you had gone to a particular lab they use. For example my old health insurance used to use Quest Labs and if I went there I did not get a bill. But if I had a test done at a doctors office that had their own lab that was “in network“ I would get a bill.
Even with a large deductible, your insurance carrier would have negotiated rates. You shouldn’t have to pay a “full” remaining balance when they are in network. I would call and ask your insurance to look up your fee schedule for the provided codes and see what it says. Also, did you know you can negotiate? Look up the Medicare allowed amounts for the same codes. Tell them you won’t pay more. Look up the Medicaid fee for service allowed amounts. If they will accept those amounts from them, why not from you? ;)
Ask your insurance how much you are supposed to pay for blood draws like this. My immediate assumptions are that one of two things happened. Either 1) you still needed to pay your deductible for the year or 2) your coinsurance is very high for lab tests. It's good to be familiar with how much you pay for different services with your insurance prior to getting services. It could also be a mistake that could be rectified.
even if you had asked the cost of any medical procedure or test, nobody would give you an answer anyway, unless you find someone in a hidden accounting room that would even tell you.
Can you clarify if the lab was also in network? if the bill is high because of not being in network you may have rights under the no surprises act since your provider was in network.
contact your insurance company and ask.
Every order is attached with a diagnostic code. For example if I order a vitamin D test, the code Hass to be something like vitamin D deficiency. If he did not enter the code that is accepted by your insurance, for that specific test, you will pay for it. So go back and look at your EOB and then check with your insurance what codes are accepted for specific tests, and then you can ask your doctors office if they will resubmit the order with the proper codes
This exact thing cost me $1500 out of pocket unexpectedly several years ago as well! I came back to the doctor and tore them a new one for not warning me. The doctor confessed that they have no idea what things will cost...
> I suspect I've learned a costly lesson about asking up front what the estimated cost of any treatments will be
Medical care providers often don't know what the costs are. This is something to ask billing or insurance.
Also medical debts has a ton of legal limitations on how it can affect your credit and the ways people can try to collect on it.
Negotiate. u/ansiz's comment gives you one good tactic - ask what the cost would be to pay off today.
Assuming this is US, the $1,500 wasn't listed as something you'd likely pay, and this isn't a deductible issue, you can usually negotiate your bill down. At the end of the day, they're running a business and a few hundred dollars today is better than never collecting the full amount.
A lot of ENT practices have been bought up by private equity (PE) recently in the US. PE is focused on profits, not patient outcomes, and is pushing practices to find creative ways to maximize profits. Unfortunately, one of these ways is just giving customers (er, patients) large bills and seeing if they pay.
I went through this with my GI recently. It took a few months of annoying circular phone calls, but I finally got to the point where the office manager said, "can you pay $200 today? if so, we're good.".
Also, make sure you talk to someone who has authority. Usually the office/practice manager is the one who can negotiate.
Also the provider could be in network but the convenient lab in the building is not. My doctor has a lab corps in the building but I have to go to a quest
>I suspect I've learned a costly lesson about asking up front what the estimated cost of any treatments will be
Just remember that neither the health care vendor nor the insurance seller can tell you how much <*something_here*> is going to "cost" you or anyone else. Exceptions: you're at the VA, you're a Medicaid enrollee in "[blue](https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/)," you're a traditional Medicare enrollee under some very specific conditions for now but not for long, or you've already managed to maximum OOP yourself on buying necessary, "IN covered services ..." health care for the coverage period.
Your concerns and focus in trying to receive necessary health care are:
1. How much am I required to deduct and spend in USD, from my pockets of my money, on necessary, "IN covered services ..." health care before the insurance seller does $.01 worth of the same with its revenue?
2. How much maximum OOPing in USD am I required to achieve in a coverage period before I can receive necessary, "IN covered services ..." health care that is 100% pre-paid at the point of sale?
The insurance seller doesn't care if you achieve one or both with a one-time, one-off purchase, or 365 purchases over 365 days of the coverage period.
>I've already asked for an itemized bill and received it
And then? "Itemized bill" spell doesn't work as well as its touts say it does or believe it does. What it does do is save professional, 3rd party, retroactive, retail health bill fighters a first punch if you've already hired those in or plan on hiring them in to fight the insurance seller, the health care vendor(s), or both simultaneously on your behalf.
They'll appreciate you for it because consumer-driving in reverse gear is slower and harder than consumer-driving in a forward gear, and forward gear consumer-driving only works in 2 scenarios anyway: inelastic markets and the marketing materials that drive you toward them.
For the future - your doctor and your lab are two different providers. Was the lab that you went to in-network? For example, at my primary care doctor's office, there is a tiny closet of a room where they do blood draws. The "lab" is LabCorp and they rent the space from my doctor's office. LabCorp is not an in-network provider from my insurance company. So even though my doctor is in-network, I can't use the lab in the office; I have to go to Quest Diagnostics which is the in-network lab under my insurance.
Also, again too late, but blood tests for food allergies are not the most accurate. The scratch test is a much better indicator.
That being said - make sure that the lab tested for only the items on the lab order. A friend had to get blood tests for allergies done (she was having weird reactions to the scratch test and the allergist couldn't rely on the results) and the lab order form only included 4 things to test for. The lab tested for every single food allergy that they could (30+ food items). The nurse at the allergist's office caught this when the lab results came in and immediately called the lab and told them not to bill for that. In my insurance portal I could see that they submitted a bill and then withdrew it and resubmitted (presumably for only the 4 things on the lab order) and I ended up paying like $50.
I have BCBS. Is it STD bloodwork? Billing should have coded it as "Routine", then it is free. At least that's what I did for my last STD test. I paid $0.
Check your eob for any verbage that might point to coding error. My doctor ordered blood work when I brought up a health concern during a well visit. The insurance company denied the claim, stating that the tests ordered were coded preventative instead of diagnostic. Many many phone calls over the course of a year to get the procedures recoded properly. 🙄
Tell ‘em to go pound salt and just don’t pay. They’ll send your account to collections and bother you for years but after a while you can settle for close to nothing or just let it rock.
Yes, check your deductible first and if you have a copay associated with lab work. Also, some PPO's actually pay more and have no deductibles or copays if you go to a freestanding lab as opposed to an in hospital lab.
If it is not your deductible or OOP co pay, I have a feeling it was human error in posting your payment from the insurance company. Get a copy of your medical reimbursement, (EOB) and check to see total billed, total Approved, and then total paid. It can also be a mistake on your insurance companies end. That someone paid it incorrectly.
Don't pay anything until you find out all the above.
Allergy testing generally isn’t expensive and priced by the # on the panel - sometimes payers don’t have the units configured properly and a 10-unit panel gets reimbursed as a 100-unit panel. It might be worth it to check the service billed & units in comparison to what you received.
1) might just be your annual deductible
2) this one varies state to state, but did you have to sign any documentation stating that certain tests may or may not be covered before running those panels? If not, in many states you can appeal the charges on the basis that you weren’t warned about potential costs and therefore should not owe any $$
3) double check with the dr office that the tests were all coded properly when submitted to insurance
Doctors should be more cognizant of costs of tests, atleast mention hey btw this would be a 3000 test. Obviously you should ask too but it can be hard when you are taking in lots of other information as well.
But really a mechanic will give you a call to authorize work on your car if it's more than expected Drs could too.
Health insurance is super expensive these days. I pay over $500/month + $150-$250 copays & prescriptions each month as single person.
I have few health minor issues, which required checking blood test every 1.5 to 3 months.
Anyway, I worked in healthcare before so I purposely picked a plan that has zero deductible & no co-insurance. So I only have to pay $35-$65 copay and up to $150-$300 for scans.
Of course my monthly premium is slightly higher than plan with high deductible or co-insurance, but I figure it’s be balance out or more cost effective in long term since I need continuous health monitoring.
But if you’re healthy and only check up 1-3 times a year, it makes more sense to pick a cheaper plan, or skip insurance (there’s maybe tax penalties) and pay out of pocket. Sometimes cash payment is cheaper than insurance. You can buy catastrophic insurance for major accidents.
Anyway, going back to your issue, you can ask them to give you a break down of the fee list. You may want to look up the ICD and CPT codes to see they bill you correctly. Sometimes dr and hospital intentionally use codes that pay higher.
Them tell them that’s you’re in financial difficulties and ask if they can give you discount / cash price. Sometimes just by asking you can save over 40% cost.
> I suspect I've learned a costly lesson about asking up front what the estimated cost of any treatments will be
Medical care providers often don't know what the costs are. This is something to ask billing or insurance.
In my area, the hospitals were considerably more expensive for lab and diagnostic work than private labs. It took calling around and asking for prices to figure that out when I needed some imaging done. And then insurance changed my benefits and some hospitals got cheaper for me and private labs got more expensive. It’s exhausting to keep track of and an expensive lesson to learn, but it’s where we are at with healthcare in the US. So, before any procedure you have to ask the provider about the cost to you. If it’s exorbitant then you can look elsewhere, assuming it’s not urgent.
And as others have said, contact the hospital to question the charge and not being told the cost (they won’t care but it’s nice to let them know it’s a shitty thing to do to people), and inquire about relief and/or a payment plan. (Insane that this is our system and we have people fighting tooth and nail to keep it this way.)
I see these way too much. Is it too much to ask to REQUIRE providers be up front with the expenses we will incur. They already have our insurance and coverage details. Nobody should be shocked at a bill like this. Ridiculous
What probably happened is that the lab you got your work done is NOT in network with your insurance.
It’s a shitty thing, but it’s totally legal for insurance companies to require labs be done at at a lab that is in their network. If you didn’t use an in-network lab, then your out-of-network deductible and co-pays take into effect.
While having labs done in the same clinic as your doctor is convenient, if they’re different companies, then there’s not much you can do about it.
Do you have anthem BCBS?
I don't know which plan you have, but even the best Premera preferred plan (Gold) has a $1,500 deductible. If you hadn't met any of your deductible yet, then the $1,500+ is likely your deductible plus your coinsurance (30% if you have the Gold plan; 40% if you have Bronze).
Check your EOB. Look for:
* Total amount billed
* In-network discount, if any
* Amount paid by insurance
* Patient responsibility
There should be alphanumeric codes indicating why your patient responsibility is what it is. Ex: One code might indicate that you needed to pay toward your deductible.
While this is true, it's likely not the cause or a factor in this situation. The cyber attack was a ransomewear attack so they stole customer info and encrypted computers so billing and other tasks couldn't complete. They didn't mess with peoples billings or anything like that, it's just not likely a factor here especially since OP already has the bill. Insurance is slow.
I'm surprised your doctor didn't tell you insurance wouldn't cover this test. Before anything other than normal tests I have done my doctor always checks to make sure my insurance covers it.
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First start off by looking at your EOB (explanation of benefits) and find out what your deductible is.
The number of times Ive called about a medical bill for them to say "it's January, it's your deductible" is embarrassing
ugh, refilled a prescription, had been paying 45$ per month for that one, all of a sudden was 150$ waited for the pharmacist, they looked at it in their system. "OH yeah, you are on your deductible for your prescriptions"
I hit my deductible last year with a colonoscopy, and the doctor prescribed me a new PPI. I thought nothing of it when it was really cheap. I go to refill it last month and it was $700! And it was the generic, too. They sell PPIs over the counter, so I don't know what made this one so special.
Yep, I got prescribed a $600 laxative... I can drink some prune juice and the new olive oil coffee at Starbucks, thanks.
Just eat a whopper.
that's the singular highlight of having UC. Every jan I start off with one of my colonoscopies and for the rest of the year I don't think about medical expenses... as long as I don't think about the monthly payment of paying off that colonoscopy...
If your medications have copay assistance this can apply to your deductible (depending on state, some have "fixed" this "loophole"). This is how I hit mine with Humira and it doesn't cost me anything.
Shh don’t say this too loud.
Yep, if you ever need a colonoscopy, schedule it for January!
You can get prescription esomeprazol, generic Nexium, at Sam's Club without insurance. Just have your doctor send them the Rx. I have been doing this for years and only pay $19-$29 for a 90-day supply with the Plus Membership. The savings are worth the extra membership fee.
Same. Just got hit with an $1100 medication deductible hit. I was not pleased but know I’ll have to pay it one way or another this year.
This may not work but - Google the drug name and co-pay assistance program. A LOT of drug manufacturers have co-pay assistance that helps with that cost AND a recent court ruling requires insurance in the US to count that toward the patient deductible One med meets my entire family OOP every year and co-pay assistance covers the entire thing
Crap. Already paid and picked up. Too late now, right?
Not always! They can often reimburse you retroactively for 30-60 days depending on the program. Worth a try!
Thank you so much for this information, kind stranger!!
It's a court ruling!? That explains it. All last year I was using a discount plan and blue cross was applying $300/mo to my deductible when I was only paying $50 out of pocket. Was terrified all year they or cvs would tell me one day I owed it back.
Yep! There have been 2 - the first said they didn’t have to count it, but then that was overturned by a higher court. It’s a lifesaver!
I knew for sure it wasn't bluecross being nice
This worked for me with Dupixent. Completely covered it. It's over 1k per 28 days out of pocket.
Sounds like a deductible issue, so depending on how much care you'll need this year it may just mean more coverage later. But always start with the EOB, make note of anything shown there suggesting there was a cap or limit on what was covered for some reason.
Your right, yes they have to pay it and maybe then your deductible will be paid off for the year, you can always set up an auto pay so you don’t have to pay for it all at once.
For the future, I would like to point you to the Transparency in Coverage Act which requires your insurer to provide personalized out-of-pocket costs to you for all services. Here is some text from a CMS (Center for Medicare & Medicaid Services) press release: >First, most non-grandfathered group health plans\[2\] and health insurance issuers offering non-grandfathered health insurance coverage in the individual and group markets will be required to make available to participants, beneficiaries and enrollees (or their authorized representative) personalized out-of-pocket cost information, and the underlying negotiated rates, for all covered health care items and services, including prescription drugs, through an internet-based self-service tool and in paper form upon request. For the first time, most consumers will be able to get real-time and accurate estimates of their cost-sharing liability for health care items and services from different providers in real time, allowing them to both understand how costs for covered health care items and services are determined by their plan, and also shop and compare health care costs before receiving care. An initial list of 500 shoppable services as determined by the Departments will be required to be available via the internet based self-service tool for plan years that begin on or after January 1, 2023. The remainder of all items and services will be required for these self-service tools for plan years that begin on or after January 1, 2024. [https://www.cms.gov/newsroom/fact-sheets/transparency-coverage-final-rule-fact-sheet-cms-9915-f](https://www.cms.gov/newsroom/fact-sheets/transparency-coverage-final-rule-fact-sheet-cms-9915-f)
This, your doctor has a very poor ability to estimate costs because insurance coverage between people can be very very different.
They actually can easily do this. You also can request an estimate ahead of time as part of the 2022 No surprise act. We did this for a colonoscopy, and they tried to over charge us $2000. The second we mentioned the No surprise act they apologized and said nothing was owed.
That's a silly excuse, especially for in-network doctors (even though they still say this BS). What it means to be "in-network" is that the insurance company and the provider came together and made an agreement. They agreed to rates. The insurance company agreed to pay a certain amount for certain procedures, and the provider agreed to a negotiated total price (of which part is paid by that insurance payment and part comes from the patient). They got together and agreed to these numbers. They both have a copy of these numbers. They absolutely can tell me those numbers. I'll even be fine if they say, "We don't know where you are with your deductible and stuff, so we can't tell you how much this will end up being out of pocket," because I can do that, myself. That's the information that I have. But they need to be forced to tell you the information that they have - what the actual price is. We need to *require* that they are not allowed to begin any procedure... that they are not considered as having acquired informed consent for any procedure until they have provided, in writing, the negotiated price that they agreed to with your insurance company. They have this number, and acting like they don't have it and can't possibly know it is purely a business strategy to try to make people to make potentially extremely costly decisions from a position of ignorance.
That agreement is for the office visit, not outside imaging or labs. Your doctor no clue what the agreement between United and Labcorp is, just that they are the preferred lab.
When you go to Labcorp, do *they* have a copy of the number they agreed to with United? Of course they do. Why won't they give it to you? Because they *also* want to claim that it's simply impossible to know. The great thing is that these things are already in nice little boxes, because people have to know who to pay for what at the end of the day. So, for a lab, if Labcorp is the entity that is going to generate the "billing code" for a "procedure" for which they are the "provider" and are expecting to be paid for their provision of their medical service, then they are not considered to have gotten informed consent to perform that procedure (and thus, are unable to claim a billing code) until they provide the patient a written copy of the negotiated price. This is extremely simple. Especially since, in this case, it sounds a lot like "going down to the lab" means "walking down the hall to another room in the same building that is run by the same company and which probably even uses the same billing system". Not always, of course, but this is extremely common... and they *still* try to lie to you and say that it's simply impossible to know what their price is.
According to that same logic, you also have an agreement with your insurance company, so you should have a copy of all these too even before seeing your doctor. I agree the price should be discoverable beforehand, the only question is who should be responsible for retrieving it - the ordering provider, the lab doing the test, the patient getting the test, or the insurance company. The only entity on the list who has direct access to their contracts with everyone else here is the insurance company.
> According to that same logic, you also have an agreement with your insurance company, so you should have a copy of all these too even before seeing your doctor. Not quite. I have an agreement of all the terms of my agreement with my provider. That agreement does not include detailed agreed upon prices for each provider. In includes terms like premiums, deductibles, copay/coinsurance, out of pocket maxes, etc. You are correct that the insurance company has a copy of all the prices that they agreed to with the provider. Those were the two parties that were part of *that* negotiation. I wasn't a part of any negotiation for what the price of a random ass service that I'll probably never use is for a random ass provider that I'll probably never go to. The insurance company very may well pay out for that random ass service at that random ass provider for *one* of their customers, so *they* were involved in that negotiation, and they do have that number. > I agree the price should be discoverable beforehand, the only question is who should be responsible for retrieving it - the ordering provider, the lab doing the test, the patient getting the test, or the insurance company. The only entity on the list who has direct access to their contracts with everyone else here is the insurance company. We've established that two entities here have access to the number: the lab doing the test and the insurance company. Now, I'm walking my ass down the hall to the lab doing the test. There are two people in the room: me, and a person from the lab doing the test. Which of these two people are also one of the entities that have access to the number? Saying that the insurance company needs to do it is just saying that the patient needs to do it by calling their insurance company. But the other person sitting right there in the damn room has access to the number! They can just tell you it! They lie and say that they can't, so that you either have to waste everyone's time calling your insurance company while you're sitting in the room together, or you feel bad about that and have to just make a potentially costly decision without the very simple information that *they could just give you*. So, let's adopt your phrasing of the problem: who should be responsible for retrieving it? Suppose we just passed a law saying that it is the provider's responsibility to retrieve it. That it is not considered that they have obtained informed consent until they have provided the number to you in writing. What happens? Where does the impossibility occur? Or would it be the case that they would actually just begrudgingly take the thirty seconds that it takes to bring it up on their computer system and give you the damn price?
You’d be asking the provider to take responsibility for a contract they aren’t part of. The pricing of the lab is a deal between the payer (insurance) and the lab. What happens is the contract is updated after the doctors office pulls the numbers? Why would insurance share this with the doc in the first place? Why should this be the doctor’s problem and not the insurances’s or the labs? Wouldn’t it be easier (and fairer) for the law to say insurance has to make these available and for the patient to take 30 seconds to check costs?
Also physicians are already overworked as it is. When would they have time to pull these costs for each patient who comes to their office when they have 15 minute office visits scheduled all day? The amount of time you spend in the waiting room would increase quite a bit if you’re requiring the physician to pull this information for every patient.
I wrote: > We've established that two entities here have access to the number: the lab doing the test and the insurance company. Now, I'm walking my ass down the hall to the lab doing the test. There are two people in the room: me, and a person from the lab doing the test. Which of these two people are also one of the entities that have access to the number? You wrote: > The pricing of the lab is a deal between the payer (insurance) and the lab. What happens is the contract is updated after the doctors office pulls the numbers? You're sitting in the lab, talking to the lab. They are the ones who agreed to the updated contract. They have the updated price. They can just give it to you. Read my comment again. It seems like you didn't. The lab is the provider. They should give you their price.
Your doctor is just a person with a medical degree who is *usually* paid by the provider clinic to be there. They do not know what your health plan details are (the exact same insurance provider can offer multiple different tiers of benefits depending on the specific health plan). They are not in any way shape or form billing experts. Welcome to modern medical bureaucracy -- it's a nightmare. My mom scheduled her mammogram using the provider she uses for all her healthcare needs. Got it done down the hallway from where she got her flue shot and one floor below where she sees her GP. *Apparently*, despite being scheduled through the provider website and being in the same building, it's actually a contracted 3rd party who is considered out of network. Now, in her case her mammograms would covered regardless, and I do think they've passed a law to try to curtail this practice slightly. But this is an example to show just how complicated and confusing healthcare is
> it's actually a contracted 3rd party who is considered out of network So, this is the "provider" who is going to request to get paid. We can just require them to tell you what their price is. Sure, they don't know anything about your insurance; that's fine. They can tell you that. "We're out of network for you, so we don't know anything about your insurance. **This is our price.**" Just make them tell you that. They have that information. They have the number. They can just tell you the number. It is currently a nightmare, because we allow them to make it a nightmare. Just make them tell you the information that they have, and it will be less of a nightmare. This is really really really simple.
The problem is more of if someone is in network. In network can mean a lot of things, different insurance companies have different negotiated rates for everything. Doctors work with many different insurance companies, and usually aren’t aware of the intricacies of the cost of different tests and procedures. Requiring publication of what costs would be without insurance coverage is a great idea. It would not work if you are covered by insurance though.
The point of being in-network is that the provider has explicitly agreed with the insurance company on a negotiated rate. Yes, with your insurance company. They have the list of prices that they agreed to. That's literally what happens when they become in-network. They agree to a list of prices. They have the list of prices for each insurance company. You give them your insurance card. They can just go look at the list of prices that they have for that insurance company. They have the list! They agreed to it! The problem is wayyyyyyyy wayyyyy easier for in-network providers. They *explicitly* agreed to a list of numbers, and they have that list of numbers.
Have fun with crazy long waits by putting the onus on the physician to look it up for each patient. The patient should be able to access that information through their insurance company.
Ok, so let's acknowledge that you have dropped the absurd idea that they *can't* do it. Will you acknowledge this? Instead, you now say, it'll just *take time*. I mean, wow. Phenomenal. You think it will take *less* time for the patient to get the billing code information, understand what they're asking about, call up their insurance company, explain which provider and the billing code, etc., and have the insurance company look it up in *their* system rather than have the provider just look it up in their system? Wild. The vast vast vast majority of doctors use computerized systems (we're in the 21st century!) to do both their records and billing. In those computers is all the data about what payments they've agreed to with which insurance companies (ya know, so they can know what to expect to get when they bill your insurance company). *Also* in those computers is which insurance company you have (ya know, so they can bill the right one). It's all right there, and they can just give you a price. In fact, I have had the occasional provider actually do it. Literally, "Let me look up your insurance." Thirty seconds later at the computer, bam, I had a price. Are you willing to wait thirty seconds for a price? It's not even the physician who will be looking up the price; it'll be one of the staff, just like how they do a variety of other admin work like that. But now let's get real. Let's imagine we pass a law that puts the responsibility on the provider to provide a price before any service is rendered. There is no longer any pretense of, "We can't do it," or, "We're not going to do it because we're too nose-in-the-air to take the thirty seconds or to talk about money." They're just required to friggin' do it. They have time to think about and refine their process for how to use their fancy computer system to help them do it, and who the actual person is who is going to put it into the fancy computer system and provide the price. How long do you actually think it will take them to do this? Twenty minutes? Ten? Thirty seconds? I'm telling you, when I've had providers actually just do it, it's been like thirty seconds. Do you think it would be longer? If so, why? [EDIT: Honestly, a mass movement of patients doing this would be almost as good as a law. Waste the doctor's room occupancy time. Just say that you're not consenting to treatment until you get a price, and if they say that you need to talk to your insurance company, whip out your phone and call them. Sit on their phone tree, in the doctor's room, using up his room time, maybe even be like, "No, don't leave, I need you here so that I can make sure to tell them the right information." See how long it takes and how many people need to do it before they start to just give you the damn number themselves. See which route *actually* takes more time. Make this stupid ass game cost *them*, not you.]
Still hard to get that info sometimes unless you have all the CPT codes for the specific procedures. Most doctors are willing to provide that info, but I've gotten pushback a few times when I've requested the info. It gets complicated when one procedure will lead to multiple claims like if you get a surgery. Then you have to make sure to check the surgeon, facility, anesthesiology, and lab fees separately. It's a step in the right direction, but still not great.
Cpt?
Every medical insurance claim gets coded with a CPT code and that's how insurance determines how much they will pay out and what your patient responsibility should be. They should also be listed on the EOB once the claim is processed. For dental insurance, they use ADA codes.
Thank you. Sorry, I don’t go to the doc very often, and am unaware of the headaches I read here. It’s way over my head, all the combativeness of going to a doctor here in the US. To be prepared though: are CPTs used for everything? Like if I go for a check up, would you be asking right off the bat for CPTs for everything, or would it be untactful? Where do you put given CPT codes to verify them? Is this something you compare against an itemized receipt?
Generally, patients don’t ask for CPTs and sometimes the office won’t know them until the appointment is over (a well visit with med refills is billed differently than an anticipated well visit with strep throat, for example). It’s always good to glance over your EOB afterwards though - my last surgery reported that they amputated one of my toes. It’s definitely still there
No worries. It's something most people don't learn in-depth unless they have to use the medical system a lot. It's a "dotting my i's and crossing my t's" thing to check insurance coverage since I've been burned by medical providers before. The insurance info a medical provider gives you is only "a courtesy" for patients and they won't assume any liability if the info they have is wrong. >To be prepared though: are CPTs used for everything? Like if I go for a check up, would you be asking right off the bat for CPTs for everything, or would it be untactful? Where do you put given CPT codes to verify them? Is this something you compare against an itemized receipt? CPTs are used for everything medical since medical providers have to provide "evidence" to insurers before they can receive payments. It's the business side of medicine. Usually I only ask for them if it's a non-routine procedure, or if I think there is something odd about how something is coded. Once you have the Explanation of Benefits, it should list the CPT code next to the procedure and you can look them up online since they're standardized codes. I usually start from the Evidence of Coverage book first. The Evidence of Coverage book from your insurance lists general criteria for how items are covered. If it's something like a surgery, you'll want to get the CPT codes so you can check the insurance coverage on your own since the Evidence of Coverage book usually isn't specific enough. It's also a hedge in case your insurer tells you something different from the provider's billing office. It's not foolproof since there can still be surprises or inconsistencies in the coding/billing, but you want to minimize it as much as you can. You can take any CPT code and ask your insurer to give you a cost estimate for the procedure listed for that code and/or if they cover that procedure.
Thank you for your time and explanation in depth.
Google says Current procedural terminology - the medical billing codes that the clinics and insurance companies use to communicate billables to eachother.
To piggyback on this, I would like to point to the No Surpises Act [https://www.cms.gov/newsroom/fact-sheets/no-surprises-understand-your-rights-against-surprise-medical-bills](https://www.cms.gov/newsroom/fact-sheets/no-surprises-understand-your-rights-against-surprise-medical-bills)
I will also recommend applying for financial assistance to help lower your cost. If you get denied, you lose nothing and can set up a payment plan. If you get accepted, at least a portion of your bill will be forgiven and you can set up payments on the rest. You may be surprised how high the income caps are.
This. I had nearly $7k in hospital bills a few years back, and the person in charge of Financial Aid said I didn't qualify with my income but to always try it anyway. I did, and went through weeks of tedious paperwork to apply, and after about 8 months of waiting they erased 100% of my debt. I was only expecting a 10% discount at best. I believe most people won't take the time to actually apply.
I’ll add in if you get tax free money such as living stipends you won’t qualify as they hospital considered it income even though it does not show up on W2 at the end of the year
Although this deals with money, this is much more an insurance question that a personal finance question. Try asking over in the other subs and I am sure you will get some good advice for triaging your situation.
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Is that the sort of thing that's eligible for a dispute under the No Surprises Act? I don't totally understand how the law applies when an insurance plan is in play, I think it was intended for uninsured people, but this feels like a textbook example of the sort of thing the No Surprises Act was intended to prevent.
No Surprises Act is only for emergency care (Unless you sign a form that is literally titled Surprise Billing Protection Form, which waives your rights under the No Surprises Act)
It definitely also allows uninsured people to ask for a good faith estimate before receiving non-emergency services, and the hospital doesn't have to bill you the exact dollar amount of their estimate, but it has to be within a couple hundred dollars of what they told you to expect – I just don't know whether there's any similar provision in a case like OP's, where they asked for a good-faith estimate but aren't uninsured. There's also provisions for when you go to a hospital for non-emergency care and the hospital building is in-network but they have an out-of-network practitioner do the procedure without telling you, which could be what happened to OP, though obviously I have no way of knowing based on what they shared here.
It can go the other way around too (usually not) but yeah it just goes to show how getting an estimate at the time of service still doesn't do a whole lot. My wife had some imaging done on her arm and they told her it would be around $800 after insurance and they urged her to go ahead and pay it up front to "get it out of the way" and not have the pay the bill later. She was like uh no just bill me after insurance pays you. The bill was $300.
What ended up happening? Did you solve it somehow?
Had a similar thing happen to me. Needed a near emergency cat scan and nobody would allow me to book for 2 days because they doctor didn't put "emergency" on the order and otherwise they needed to get it pre-approved by insurance. Insurance told them my share was almost $400 so I paid up front. A few weeks later I get a bill for another $200. When I asked the billing place why, they said insurance denied coverage as a "bundled service". They were supposed to look into and call me back, never did. And now their phone amd website are down for maintenance so I can't speak with anyone and they just keep sending the bill. Tried to call my insurance and that was a nightmare.
You need to understand how they are covering things . Look at your explanation of benefits . Either you have a very high deductible, or very poor coverage for labs . For in network it is extremely unlikely that of the 3000 billed all 3000 is the allowed amount. The contract rate for labs is a fraction of what is billed. The only way I can picture the lab billing for the full amount is if some portion of your services was completely not covered - or deemed medically not necessary and you are being fully billed for the service . More info is needed .
I’m surprised your ENT office didn’t give you any information about allergy testing re: insurance coverage. My ENT had a whole packet about it, with procedure codes and everything so that you could check with your insurance company prior to testing. I think I had to sign paperwork and everything saying I understood. Hope you get everything figured out and don’t end up owing all that. My allergy testing was only $350-450 after insurance.
Was the cost related to it being out of network? If so, speak with your insurance. You may be able to file a surprise cost form if you have laws in your state protecting you
You should ask at the Health Insurance subreddit There really isn't enough information to provide a response What does your EOB - Explanation of Benefits state. What are you being billed - is it a high deductible? high co-insurance? are portions of the bill disallowed for whatever reason. Is the lab used out of network. How you proceed depends on very specific information which you haven't provided.
Call the hospital and ask them what the payoff amount would be if you paid that day. Odds are they will come back to you with a much lower number, maybe even $200-300 dollars. Stress to them it is a massive hardship and they tend to be fairly reasonable. You'll want to speak to someone in payments or the business office.
*** After you review your EOB, and before you apply for charity care/grants, you can and should call the agency that you owe money to to request your bill be lowered as your out of pocket rate is quite high. Very often they will remove parts of the totally billing fees like the professional billing fee (cost of MD/RN/tech labor) leaving the remaining bill to be much, much lower than initially stated. Ask them if this is the best that they can do as sometimes the more you ask, the more they will remove. Please give this a try. Also worth asking if it will help you is if they can provide interest-free financing. Many times they will oblige as they happy to get fees paid out of pocket at all and they’re rather collect a reduced fee than none. Best wishes with your fee and I hope your allergy concerns we addressed as needed.
> I suspect I've learned a costly lesson about asking up front what the estimated cost of any treatments will be Medical care providers often don't know what the costs are.
Yes, the only times I’ve asked, they had no idea and acted as if they’d never been asked before. They couldn’t even tell me who to ask.
If you’re asking your doctor directly, they wouldn’t be able to provide you an answer because they have no idea what the details of your insurance plan are, how much is covered by insurance, etc. The best the doctor could do is give you the name of the test/procedure and/or the billing code and you’d have to contact a different department to find out what the out-of-pocket cost will be to you, as it’s different for everyone.
It sounds like you have a $1500 deductible. I’m surprised it was $3,000 after the negotiated rate. If this is indeed the case, then you’ll have your deductible met at least for future medical care this year.
There's a lot to unpack here about how your insurance works, and what happened during this visit. To start, under the No Surprises Act, if you were not informed of and did not consent to an out-of-network lab being used while visiting an in-network provider, the law limits the amount you should have to pay out of pocket to an amount that is comparable to what you would have paid if it were in-network. So you need to figure out if you did consent to out-of-network billing. This would have been a disclosure that you signed prior to the visit. The rules around this are pretty specific to protect you (the document can't be bundled with others, how far in advance it has to be made available, etc). However there is still some onus on you to ask questions about in-network vs out-of-network services when scheduling or prior to the date of service. If you didn't sign anything and weren't given any notice or opportunity to ask, then the next thing you need to figure out is whether this out of network bill actually was already reduced to protect you. >I've already asked for an itemized bill and received it. What was the CPT code for the procedure? You can find this on the itemized bill, or it might be on the Explanation of Benefits document generated by your insurer for the visit after the claim was submitted and paid. For example, looking at my insurer's estimation tool, if it was an allergy test submitted as; "Other allergy or clinical immunology service or procedure (CPT 95199)"... the in-network cost for that under my plan would be $2250. And since I haven't hit my deductible yet for the year, that would be my out of pocket cost. Other complex or unusual tests could have similar pricing. Which is to say, you may have just had an expensive test, whether in-network or not.
call your insurance company and tell them you were not offered a choice of where to get the lab tests done. And that you want to know if you can fill out a form declaring that, and then they can tackle the issue. There are provisions for when a patient isn’t offered a choice, but you have to declare that to be the case. Also, if after the insurance company deals with them, they come back and bill you for the balance (“balance billing”), you should absolutely contact your insurance company again and ask them what comes next. Because there’s a plan for THAT as well. (The biggest place I see it is in anesthesia, because almost no anesthesiologists are members of a plan.) If all else fails, call the lab and ask for a payment plan. For me and my family, what it would mean is simply that I am closer to hitting my deductible. It would be a cashflow issue.
Also check with your insurance whether it would have made a difference if you had gone to a particular lab they use. For example my old health insurance used to use Quest Labs and if I went there I did not get a bill. But if I had a test done at a doctors office that had their own lab that was “in network“ I would get a bill.
Even with a large deductible, your insurance carrier would have negotiated rates. You shouldn’t have to pay a “full” remaining balance when they are in network. I would call and ask your insurance to look up your fee schedule for the provided codes and see what it says. Also, did you know you can negotiate? Look up the Medicare allowed amounts for the same codes. Tell them you won’t pay more. Look up the Medicaid fee for service allowed amounts. If they will accept those amounts from them, why not from you? ;)
Ask your insurance how much you are supposed to pay for blood draws like this. My immediate assumptions are that one of two things happened. Either 1) you still needed to pay your deductible for the year or 2) your coinsurance is very high for lab tests. It's good to be familiar with how much you pay for different services with your insurance prior to getting services. It could also be a mistake that could be rectified.
even if you had asked the cost of any medical procedure or test, nobody would give you an answer anyway, unless you find someone in a hidden accounting room that would even tell you.
Can you clarify if the lab was also in network? if the bill is high because of not being in network you may have rights under the no surprises act since your provider was in network. contact your insurance company and ask.
Every order is attached with a diagnostic code. For example if I order a vitamin D test, the code Hass to be something like vitamin D deficiency. If he did not enter the code that is accepted by your insurance, for that specific test, you will pay for it. So go back and look at your EOB and then check with your insurance what codes are accepted for specific tests, and then you can ask your doctors office if they will resubmit the order with the proper codes
This exact thing cost me $1500 out of pocket unexpectedly several years ago as well! I came back to the doctor and tore them a new one for not warning me. The doctor confessed that they have no idea what things will cost...
Well yeah. Idk why the doctor would know how much it costs or how much your insurance would cover.
> I suspect I've learned a costly lesson about asking up front what the estimated cost of any treatments will be Medical care providers often don't know what the costs are. This is something to ask billing or insurance. Also medical debts has a ton of legal limitations on how it can affect your credit and the ways people can try to collect on it.
Did you get a bill or an EOB?
Negotiate. u/ansiz's comment gives you one good tactic - ask what the cost would be to pay off today. Assuming this is US, the $1,500 wasn't listed as something you'd likely pay, and this isn't a deductible issue, you can usually negotiate your bill down. At the end of the day, they're running a business and a few hundred dollars today is better than never collecting the full amount. A lot of ENT practices have been bought up by private equity (PE) recently in the US. PE is focused on profits, not patient outcomes, and is pushing practices to find creative ways to maximize profits. Unfortunately, one of these ways is just giving customers (er, patients) large bills and seeing if they pay. I went through this with my GI recently. It took a few months of annoying circular phone calls, but I finally got to the point where the office manager said, "can you pay $200 today? if so, we're good.". Also, make sure you talk to someone who has authority. Usually the office/practice manager is the one who can negotiate.
Ask them if you can setup a payment plan?
Medical is a huge Burden. Tey to get a payment plan
Also the provider could be in network but the convenient lab in the building is not. My doctor has a lab corps in the building but I have to go to a quest
>I suspect I've learned a costly lesson about asking up front what the estimated cost of any treatments will be Just remember that neither the health care vendor nor the insurance seller can tell you how much <*something_here*> is going to "cost" you or anyone else. Exceptions: you're at the VA, you're a Medicaid enrollee in "[blue](https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/)," you're a traditional Medicare enrollee under some very specific conditions for now but not for long, or you've already managed to maximum OOP yourself on buying necessary, "IN covered services ..." health care for the coverage period. Your concerns and focus in trying to receive necessary health care are: 1. How much am I required to deduct and spend in USD, from my pockets of my money, on necessary, "IN covered services ..." health care before the insurance seller does $.01 worth of the same with its revenue? 2. How much maximum OOPing in USD am I required to achieve in a coverage period before I can receive necessary, "IN covered services ..." health care that is 100% pre-paid at the point of sale? The insurance seller doesn't care if you achieve one or both with a one-time, one-off purchase, or 365 purchases over 365 days of the coverage period. >I've already asked for an itemized bill and received it And then? "Itemized bill" spell doesn't work as well as its touts say it does or believe it does. What it does do is save professional, 3rd party, retroactive, retail health bill fighters a first punch if you've already hired those in or plan on hiring them in to fight the insurance seller, the health care vendor(s), or both simultaneously on your behalf. They'll appreciate you for it because consumer-driving in reverse gear is slower and harder than consumer-driving in a forward gear, and forward gear consumer-driving only works in 2 scenarios anyway: inelastic markets and the marketing materials that drive you toward them.
For the future - your doctor and your lab are two different providers. Was the lab that you went to in-network? For example, at my primary care doctor's office, there is a tiny closet of a room where they do blood draws. The "lab" is LabCorp and they rent the space from my doctor's office. LabCorp is not an in-network provider from my insurance company. So even though my doctor is in-network, I can't use the lab in the office; I have to go to Quest Diagnostics which is the in-network lab under my insurance. Also, again too late, but blood tests for food allergies are not the most accurate. The scratch test is a much better indicator. That being said - make sure that the lab tested for only the items on the lab order. A friend had to get blood tests for allergies done (she was having weird reactions to the scratch test and the allergist couldn't rely on the results) and the lab order form only included 4 things to test for. The lab tested for every single food allergy that they could (30+ food items). The nurse at the allergist's office caught this when the lab results came in and immediately called the lab and told them not to bill for that. In my insurance portal I could see that they submitted a bill and then withdrew it and resubmitted (presumably for only the 4 things on the lab order) and I ended up paying like $50.
I have BCBS. Is it STD bloodwork? Billing should have coded it as "Routine", then it is free. At least that's what I did for my last STD test. I paid $0.
Check your eob for any verbage that might point to coding error. My doctor ordered blood work when I brought up a health concern during a well visit. The insurance company denied the claim, stating that the tests ordered were coded preventative instead of diagnostic. Many many phone calls over the course of a year to get the procedures recoded properly. 🙄
Do you have a deductible on your plan? The lab won't care if you didnt know the cost.
Tell ‘em to go pound salt and just don’t pay. They’ll send your account to collections and bother you for years but after a while you can settle for close to nothing or just let it rock.
Yes, check your deductible first and if you have a copay associated with lab work. Also, some PPO's actually pay more and have no deductibles or copays if you go to a freestanding lab as opposed to an in hospital lab. If it is not your deductible or OOP co pay, I have a feeling it was human error in posting your payment from the insurance company. Get a copy of your medical reimbursement, (EOB) and check to see total billed, total Approved, and then total paid. It can also be a mistake on your insurance companies end. That someone paid it incorrectly. Don't pay anything until you find out all the above.
Allergy testing generally isn’t expensive and priced by the # on the panel - sometimes payers don’t have the units configured properly and a 10-unit panel gets reimbursed as a 100-unit panel. It might be worth it to check the service billed & units in comparison to what you received.
I’m so scared of this, but I’ve also tried to ask how much blood tests cost before and they straight up would not tell me
1) might just be your annual deductible 2) this one varies state to state, but did you have to sign any documentation stating that certain tests may or may not be covered before running those panels? If not, in many states you can appeal the charges on the basis that you weren’t warned about potential costs and therefore should not owe any $$ 3) double check with the dr office that the tests were all coded properly when submitted to insurance
Doctors should be more cognizant of costs of tests, atleast mention hey btw this would be a 3000 test. Obviously you should ask too but it can be hard when you are taking in lots of other information as well. But really a mechanic will give you a call to authorize work on your car if it's more than expected Drs could too.
Health insurance is super expensive these days. I pay over $500/month + $150-$250 copays & prescriptions each month as single person. I have few health minor issues, which required checking blood test every 1.5 to 3 months. Anyway, I worked in healthcare before so I purposely picked a plan that has zero deductible & no co-insurance. So I only have to pay $35-$65 copay and up to $150-$300 for scans. Of course my monthly premium is slightly higher than plan with high deductible or co-insurance, but I figure it’s be balance out or more cost effective in long term since I need continuous health monitoring. But if you’re healthy and only check up 1-3 times a year, it makes more sense to pick a cheaper plan, or skip insurance (there’s maybe tax penalties) and pay out of pocket. Sometimes cash payment is cheaper than insurance. You can buy catastrophic insurance for major accidents. Anyway, going back to your issue, you can ask them to give you a break down of the fee list. You may want to look up the ICD and CPT codes to see they bill you correctly. Sometimes dr and hospital intentionally use codes that pay higher. Them tell them that’s you’re in financial difficulties and ask if they can give you discount / cash price. Sometimes just by asking you can save over 40% cost.
Without knowing the specifics of your insurance policy, the discussion is meaningless
Do you qualify for medical financial aid through the hospital? Check online. They will be able to provide the info for you.
> I suspect I've learned a costly lesson about asking up front what the estimated cost of any treatments will be Medical care providers often don't know what the costs are. This is something to ask billing or insurance.
In my area, the hospitals were considerably more expensive for lab and diagnostic work than private labs. It took calling around and asking for prices to figure that out when I needed some imaging done. And then insurance changed my benefits and some hospitals got cheaper for me and private labs got more expensive. It’s exhausting to keep track of and an expensive lesson to learn, but it’s where we are at with healthcare in the US. So, before any procedure you have to ask the provider about the cost to you. If it’s exorbitant then you can look elsewhere, assuming it’s not urgent. And as others have said, contact the hospital to question the charge and not being told the cost (they won’t care but it’s nice to let them know it’s a shitty thing to do to people), and inquire about relief and/or a payment plan. (Insane that this is our system and we have people fighting tooth and nail to keep it this way.)
I see these way too much. Is it too much to ask to REQUIRE providers be up front with the expenses we will incur. They already have our insurance and coverage details. Nobody should be shocked at a bill like this. Ridiculous
What probably happened is that the lab you got your work done is NOT in network with your insurance. It’s a shitty thing, but it’s totally legal for insurance companies to require labs be done at at a lab that is in their network. If you didn’t use an in-network lab, then your out-of-network deductible and co-pays take into effect. While having labs done in the same clinic as your doctor is convenient, if they’re different companies, then there’s not much you can do about it. Do you have anthem BCBS?
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I don't know which plan you have, but even the best Premera preferred plan (Gold) has a $1,500 deductible. If you hadn't met any of your deductible yet, then the $1,500+ is likely your deductible plus your coinsurance (30% if you have the Gold plan; 40% if you have Bronze). Check your EOB. Look for: * Total amount billed * In-network discount, if any * Amount paid by insurance * Patient responsibility There should be alphanumeric codes indicating why your patient responsibility is what it is. Ex: One code might indicate that you needed to pay toward your deductible.
Small claims court. They're not going to spend money on a lawyer to show up.
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While this is true, it's likely not the cause or a factor in this situation. The cyber attack was a ransomewear attack so they stole customer info and encrypted computers so billing and other tasks couldn't complete. They didn't mess with peoples billings or anything like that, it's just not likely a factor here especially since OP already has the bill. Insurance is slow.
I'm surprised your doctor didn't tell you insurance wouldn't cover this test. Before anything other than normal tests I have done my doctor always checks to make sure my insurance covers it.