Health insurance "out of network" coverage question?

Question

Hi. If someone is knowledgeable about health care insurance I hope you can help. I had a biopsy done an a hospital that was in-network for my insurance company. They sent the biopsy to the only lab they are contracted with the interpret the slides. This lab was out of network. All of this took place without my knowledge. Now I am receiving bills totaling over $1000, most of which I am expected to pay because of this out of network lab. Are there any laws of policies that protect people against things of this nature, since I was never even told that my biopsy would be sent to a lab that was out of network? I want to fight this but I don't who to fight or what specifically to base it on.

Thanks.

Answer 1

There are a couple of issues here, so bear with me...

1)  Was the claim truly paid "out of network," or are you just being "balance billed"?  Its entirely possible that your insurer reimbursed the lab at the same level that an in-network lab would have received, and the lab is just billing you for the difference between the network rate and their billed charges.  (You may be aware that the insurer doesn't pay the "sticker price" for services - an in-network provider agrees to give the insurer a discount, and writes off the difference between the "sticker price" and the insurer's discount.  A non-contracted provider is under no obligation to do so.)

2)  Did the hospital use their own lab for the services, or did they send it out to an independent, non-hospital owned lab?

You absolutely must clarify the answer to those 2 questions before you proceed with any sort of appeal.  The approach you would take with your appeal, and your possible level of success depends upon the answers to those 2 questions.

Because you went to an in-network hospital, its not unreasonable to anticipate that the lab work would be processed as in-network also.  Most hospitals actually own the lab service that they use, and services done by the hospital's own lab would generally fall under the hospital's network contract w/the insurer.

(Its a different situation with doctor's offices, where lab work is often sent to different, independent labs.  But in a hospital, you generally expect that it will be handled by the hospital's own lab.)

If the hospital sent out your lab work to an independent company, you need to find out why.  Was there something special or unusual about your lab work, which prevented the hospital's own lab from doing it?  Did you have a unique service done that only a few labs could provide?  (If yes...use that as the basis for your appeal to have the claim reconsidered.  Make the argument that the service wasn't available in the network due to the specialty and/or complexity involved.)

If your claim was truly processed as out of network, you can request that the claim be reviewed for processing as in-network.  Keep in mind that this won't stop you from being "balance billed," as an out-of-network lab is not obligated to accept the insurer's discount as paid in full.  But even if it means that the insurer pays out a little extra, that's still something less that you're being billed for out of pocket.

If your insurer did pay the lab the same amount as they would have paid an "in-network" lab anyhow, and the lab is just billing you for the difference...there's not generally a whole lot you can do about that.  The insurer isn't going to pay more than they would have paid to an in-network provider.  And the lab isn't obligated to take the insurer's discount.

Those are the kinds of things you need to consider when forming an appeal - since I don't have the answers to the 2 crucial questions above, its hard for me to tell you exactly what to write.  But at least if you start thinking about these things, it will help you to formulate your argument.

(What are your odds for success?  Depends on exactly what happened.  If the lab you used offers a specialty service not available in-network, you may have a shot at getting a little extra paid.  Though it likely won't be the whole balance.)

Answer 2

Call your insurance. Most healthplans should automatically upgrade the out of network interpretation to your in network benefits. They already know you had no control over the guy who read your labs. It doesn't need to be a long, drawn out ordeal. Just call them. They can help. If the people in customer service don't offer a workable solution, ask for a supervisor... This happens A LOT. It should be ok...  Worst case, they'll ask you to dispute the charges in writing. If its not resolved quickly,  (& your insurance is provided by your employer), call Hr. If your plan is private, call your broker.

Answer 3

Call your insurance agent and simply explain it to him.  Then if that doesn't work you could go to court and most likely the company will settle.  Insurance companies hate paying lawyers to go to court when they could just settle.

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Answer 5

You are on the short stick here.  Sad to say, it is always the responsibility of the patient to insure that any work is handled by a provider within network.

That you did not insure that the biopsy work was done within network is not the problem of the carrier involved.

Answer 6

As a Health Insurance Broker, we come across situations like this quite often.  We see it with Radiologists, and Anesthesiologists more frequently than labs.  The proper procedure would be to appeal the denial with your insurance carrier first.  Explain the situation just as you did here and request that the claim be paid, as you had no choice which lab the hospital sent the sample for analysis.

Good luck.

Answer 7

There is not much you can do.

Call and talk to your health insurance and see what they will do.

You could also call the lab and see if they are willing to reduce their fee. Often medical providers will be willing to accept less for a lump sum payment - rather than have you send them 25 per month until it is paid.

There is no law that says your samples have to be sent to an in network lab.

Answer 8

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