The Medical Billing Snafu

About six weeks ago I went to the doctor’s to have some blood work done — routine stuff, mostly cholesterol, nothing my health insurance had ever balked at before. I remember my doctor saying in passing “I’m going to send it to the good lab this time”, but I didn’t think anything of it at the time.

Two weeks later, I got one of those “Explanation of Benefits” from my insurance company. Normally I just glance at these, take solace in the friendly “This is not a bill!” printed at the top, and then shred them. This one hilariously had 17 separate line items, all just identified as “Medical Services,” but, somewhat unsettlingly, also included a check for $464.43. As a pessimist, I knew this couldn’t possibly mean anything good.

I called my health insurance company and the (actually quite nice) human I talked to there gave me the scoop: the “good lab” my doctor sent my blood work to was not in my provider network. The $464.43 was what my insurance had agreed to pay for out-of-network testing; the lab would be sending me be a bill for their full charges, which would be around $1,400. He suggested that, when I got that bill, I call the lab and see if they’d just accept the $464.43 (which he said they might, which sounded insane to me) and that if they didn’t I should file an appeal with my insurance company, which he was confident would be accepted since this wasn’t a service or lab I had requested.

That was a month ago. I still haven’t received a bill from the lab. My questions:

* Should I go through the trouble of contacting this “good lab” to see what’s up? My strong instinct is that if I haven’t gotten a bill, it’s not my problem, and I should leave well enough alone. But a few years back I had a medical billing headache that resulted from one of my wife’s doctors submitting a claim to our insurance 18 months after her visit, so I know these things can lurk for one reason or another and probably should be dealt with sooner or later. (I would need to cash the check from my insurance by September, for what that’s worth.)

* Assuming I do eventually get this $1,400 bill, should I wait to go through the appeals process before I give my doctor’s office holy hell? Even if the appeal is approved, should I still complain to my doctor? If it isn’t, is there any chance that the doctor would cough up the $950 difference?

* Even if everything does work out in the end, is this a bad enough violation to dump my doctor over? I like her because her office is an easy walk from our house and you can always get an appointment on short notice if you’re sick. It’s a tiny one-doctor practice and her support staff is not always the best, which has resulted in the occasional minor billing snafu, but nothing on this scale. I relayed the “good lab” comment to the guy at the insurance company and he darkly suggested that sometimes doctors have sketchy relationships with particular labs.

Anyway, curious as to what you and other Billfolders think. The good news is that I managed to get my cholesterol down from the upper 190s to 151 in only six months! Eating better and exercising daily really does do wonders. — J.

Our health care system is quite something isn’t it?

Regarding your first question about contacting the “good lab”: A common story I often hear about has to do with someone applying for a loan or a line of credit and being turned down because of a medical bill he or she wasn’t aware of that ended up going into collections. This, plus the medical billing headache you experienced previously, would prompt me to get this all sorted out sooner than later.

As for your second point, I would—politely—talk to the doctor about the billing issue regardless of what happens and have your doctor make it clear to you when you are getting a service that’s out of your network so you won’t have to deal with this again in the future. I would wait to see if the appeals process goes through or not before bringing it up, and if it doesn’t, I’d ask your doctor for her help in negotiating the bill.

Personally, I don’t think this is worth dumping your doctor over—especially if the appeals process gets approved, or you’re able to negotiate your bill. If you like your doctor and the services she has provided you (besides this snafu), I’d stick with her unless the billing becomes a problem again.

One last thing: If the bill doesn’t make it through the appeals process and you have difficulty negotiating it, there are health care billing advocates that may be able to help: Medical Billing Advocates of America is one, and the Patient Advocation Foundation is another.

In any case, congrats on getting your cholesterol down! Thoughts from readers?


Photo: Lauren



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