Expensive med. test not covered by insurance

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mojave
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Expensive med. test not covered by insurance

Post by mojave »

A few months ago I had my annual checkup with my OBGYN. I mentioned that my husband and I may try to conceive soon and she recommended genetic testing to see if I was a carrier of any genetic diseases. I thought it over a bit, weighing the possible emotional outcomes, and then made the appointment. Everything turned out fine.

I just got the explanation of benefits and my insurance is covering a whopping $0 and they are saying that the do not cover those tests. I am going to be charged $4200 out of pocket.

I talked to my Doctor and several nurses about this test while I was thinking about it and not once did anyone recommend calling insurance or caution me about the costs associated with this. Clearly they didn't call on my behalf to make sure such an expensive test was covered. Additionally, when I was there to get the test, while the nurse was prepping me I asked for a rough estimate of what it would cost. She told me about $15 per test.

I now know I should have called myself, hindsight is 20/20. I was under the impression that this was just a simple blood test.

Doctors, what would you do in a situation like this? Would you alert a patient if a group of tests could potentially cost them thousands out of pocket? Does your office call their insurance if there is a concern about coverage?

We already have other medical bills from last summer when my husband was in the hospital with Meningitis.

Thanks for any feedback you have. Of course, I will be calling both my insurance and my Doctor tomorrow but I'm in need of a little hope.
desiderium
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Re: Expensive med. test not covered by insurance

Post by desiderium »

Unfortunately, you are most likely going to be stuck with this. These kinds of tests are not widely covered by insurance unless there are special considerations, for example a family history that would put you at high risk. Even then, it frequently requires herculean effort to get it paid by the insurance company. I think you were done a disservice by your doctors' office by not being informed of this hazard, which was probably predictable. Also, it is rare for even the most rudimentary test to cost $15, so that was a wildly inaccurate guess.

The insurance covers only procedures that are "medically necessary", and again without extenuating circumstances their response is likely going to be very cut and dried.

The lab tests were almost certainly done by another provider, not your doctor directly, so you may not have much room to negotiate. Does your doctor work for a large health care organization? If so, complaining you were not informed about this might get you some relief, but probably not.

I regret not being able to offer you much hope
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Re: Expensive med. test not covered by insurance

Post by nisiprius »

mojave wrote:I now know I should have called myself, hindsight is 20/20.
I don't like it. I don't think it should be that way. Sometimes I forget to do it. But, yes, it probably is necessary to check with your insurer any time you're about to have something done that hasn't been done before.
I was under the impression that this was just a simple blood test.
Well, to a doctor, it probably is. That is to say, a blood test is a blood test. It doesn't take long. It doesn't pose much risk to the patient. It doesn't requires the services of an anesthesiologist, a doctor, or a nurse. It's the same blood draw whether the blood is going to get a cheap test or an expensive test.
Doctors, what would you do in a situation like this? Would you alert a patient if a group of tests could potentially cost them thousands out of pocket? Does your office call their insurance if there is a concern about coverage?

We already have other medical bills from last summer when my husband was in the hospital with Meningitis.

Thanks for any feedback you have. Of course, I will be calling both my insurance and my Doctor tomorrow but I'm in need of a little hope.
My experience with doctors is that they honestly don't know anything about what insurance will or won't cover. And also that they don't want to try to guess or commit themselves. Not only are there probably dozens of insurers, each insurer has half a dozen kinds of plan (PPO, HMO, etc), half a dozen flavors within each kind, and employers can elect to add or remove specific items of coverage. Worse yet, "coding" is apparently a bit of an art. The very same procedure might be covered or not depending on the coding. To take an obvious example, the same procedure might not be covered if it's for "screening" (you don't have a known problem) but might be covered if it's part of a medical exam looking at a specific problem.

It is all completely sucky. But it's not the doctors' fault.

At this point, you need to find out something I know nothing about: can the price be negotiated down and how do you go about doing it?
Last edited by nisiprius on Mon Apr 07, 2014 8:49 pm, edited 1 time in total.
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Re: Expensive med. test not covered by insurance

Post by nisiprius »

P.S. The $15 might have been a decent guess at the fee that was charged for the phlebotomy itself--that is to say, what they charge to draw the blood, label it, log it, send it to the lab.
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mojave
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Re: Expensive med. test not covered by insurance

Post by mojave »

desiderium wrote:Unfortunately, you are most likely going to be stuck with this. These kinds of tests are not widely covered by insurance unless there are special considerations, for example a family history that would put you at high risk. Even then, it frequently requires herculean effort to get it paid by the insurance company. I think you were done a disservice by your doctors' office by not being informed of this hazard, which was probably predictable. Also, it is rare for even the most rudimentary test to cost $15, so that was a wildly inaccurate guess.

The insurance covers only procedures that are "medically necessary", and again without extenuating circumstances their response is likely going to be very cut and dried.

The lab tests were almost certainly done by another provider, not your doctor directly, so you may not have much room to negotiate. Does your doctor work for a large health care organization? If so, complaining you were not informed about this might get you some relief, but probably not.

I regret not being able to offer you much hope

Oh my god. This will destroy us. Why [(removed) --admin LadyGeek] would a doctor do this to a patient?!?!?!? Seriously, why?????

I have $800 in dental bills because of a crown. We have $1800 left with my husband's hospital stay. I have another $200 from other medical bills. Now $4200.

I used to look up to the medical industry, after this I have lost all hope and respect.
jstat
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Re: Expensive med. test not covered by insurance

Post by jstat »

What did they test for? My recollection is that they only need to test for a handful of things. I would talk to your doctor about the cost. It is possible they didn't realize the cost, and will try to get the lab to reduce the price. Or at least think twice about recommending it next time.
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Re: Expensive med. test not covered by insurance

Post by Steelersfan »

Nope, Doctors rarely do this.

I don't think they are very aware of the costs of a procedure, and with the complexity of what your particular insurance plan coves and doesn't cover, I have some sympathy for them in that regard.

I had an MRI for some shoulder pain that comes and goes and asked my Doc about it and he suggested an MRI if I want to get it looked at. I did, and about $1,000 later he said, yup, you've got a bit of arthritis in there and there nothing you can do about it. My insurance didn't cover it. Others might have.
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munemaker
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Re: Expensive med. test not covered by insurance

Post by munemaker »

mojave wrote:
desiderium wrote:Unfortunately, you are most likely going to be stuck with this. These kinds of tests are not widely covered by insurance unless there are special considerations, for example a family history that would put you at high risk. Even then, it frequently requires herculean effort to get it paid by the insurance company. I think you were done a disservice by your doctors' office by not being informed of this hazard, which was probably predictable. Also, it is rare for even the most rudimentary test to cost $15, so that was a wildly inaccurate guess.

The insurance covers only procedures that are "medically necessary", and again without extenuating circumstances their response is likely going to be very cut and dried.

The lab tests were almost certainly done by another provider, not your doctor directly, so you may not have much room to negotiate. Does your doctor work for a large health care organization? If so, complaining you were not informed about this might get you some relief, but probably not.

I regret not being able to offer you much hope
Oh my god. This will destroy us. Why the HELL would a doctor do this to a patient?!?!?!? Seriously, why?????

I have $800 in dental bills because of a crown. We have $1800 left with my husband's hospital stay. I have another $200 from other medical bills. Now $4200.

I used to look up to the medical industry, after this I have lost all hope and respect.
The doctor is responsible for practicing medicine. What your insurance covers or how you finance the payment is, unfortunately, not the doctor's responsibility. If you cannot afford to pay the entire bill now, talk to the billing office; they will usually take payments over time in cases like this. If you are truly destitute (this will destroy you), write them a letter describing your situation and ask for part of the bill to be forgiven. Provide evidence such as paycheck or tax return. It sometimes works. Be proactive before it is turned over to a collection agency.
853211
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Re: Expensive med. test not covered by insurance

Post by 853211 »

My wife and I were In a similar spot last year, OB offered up a full slate of tests and my wife luckily only agreed to one. Doc said it was covered by her plan, which it was, just for women's lot older than her. :oops:

We got a massive eob for that one and then a bill came from the lab for about 1/10th of the costs. The letter from the lab basically said "your carrier doesn't want to play ball with us but we've reduced the price for you to what they would have paid us". First time I had ever seen that.

We cut a check and she found a new OB, one that gives her the care she needs and one that is okay with me saying we need to know what they're going to do / recommend ahead of time so I can get our ducks in a row. New practice gave me the complete list of tests they run, when, and by who as well as alternatives.

Call the lab or whoever actually sent you the bill, they're the folks that may be able to help.
DSInvestor
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Re: Expensive med. test not covered by insurance

Post by DSInvestor »

nisiprius wrote:At this point, you need to find out something I know nothing about: can the price be negotiated down and how do you go about doing it?
I think this is what you should do. I recently had some blood work done as part of an annual wellness visit. According to the EOB, the initial bill was $1300. The insurance discount was $1200, then the insurance company paid something and my responsibility was something like $80. If I went for the same blood work without insurance coverage, would they have billed me $1300? Perhaps they would have settled for $100 which would have been what they would have received if I had coverage.

It may be worth calling the lab to see if you can negotiate the bill down to a more manageable amount. Maybe offer $200 going by the amount of discount seen on my lab test. Or wait for a second bill and maybe a third bill. I have waited to pay for blood work in the past (out of town for several months) and I've seen bills get smaller and smaller even though I had paid anything.
Last edited by DSInvestor on Mon Apr 07, 2014 9:20 pm, edited 1 time in total.
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Re: Expensive med. test not covered by insurance

Post by Calm Man »

This is a huge problem. You have been charged what I call the "crazy rate". Meaning if you look at an Explanation of Benefits for a regular covered test, like a complete blood count,k you will see something like: charged $150. Negotiated insurance rate $10. Paid by insurance $10. You owe: ZERO. So this nonsensical $4000 is probably $400 if covered maximum. That is your only hope if you are not wealthy. I would speak with the insurer and hope that they will provide you what they would pay if it were covered (they will likely say that they don't know). Then you could simply call the lab that billed you (if you got a bill, you may not have yet) and tell them you can't afford it,k you had no idea, cry a lot and see if they will cut you a break. If you get away for $100 or so, pay it right away. And you have learned something from this as have others. Thanks for sharing.
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Re: Expensive med. test not covered by insurance

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This thread is now in the Personal Consumer Issues forum (medical costs).
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Re: Expensive med. test not covered by insurance

Post by dhodson »

This isn't my area of expertise within medicine but I'm not seeing what or why a test was ordered. I didn't order or have ordered any such test before any of our 3 kids. I can understand that this physician might not know the cost and may even be under the false impression that it would be covered. People who market tests and medications typically give a positive impression. I typically don't see drug reps but every time I see one by accident and they tell me about their medication, I ask how much will it cost my patients and they tell me next to nothing bc of some rebate card. They know that a large percentage of my patient population is on Medicare and I have to constantly remind them that their rebate cards don't work with Medicare.
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Re: Expensive med. test not covered by insurance

Post by mojave »

853211 wrote:My wife and I were In a similar spot last year, OB offered up a full slate of tests and my wife luckily only agreed to one. Doc said it was covered by her plan, which it was, just for women's lot older than her. :oops:

We got a massive eob for that one and then a bill came from the lab for about 1/10th of the costs. The letter from the lab basically said "your carrier doesn't want to play ball with us but we've reduced the price for you to what they would have paid us". First time I had ever seen that.

We cut a check and she found a new OB, one that gives her the care she needs and one that is okay with me saying we need to know what they're going to do / recommend ahead of time so I can get our ducks in a row. New practice gave me the complete list of tests they run, when, and by who as well as alternatives.

Call the lab or whoever actually sent you the bill, they're the folks that may be able to help.
Thank you. Thank you. Thank you. I needed this little ray of sunshine, even if I most likely am SOL. I'm doing everything I can to not break down. I don't know how I'm going to tell my husband about this. I feel so guilty.
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Re: Expensive med. test not covered by insurance

Post by mojave »

FWIW my Doctor has been in the biz for ~30 years at one of the best hospitals in the Chicago area (Lutheran General).
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Re: Expensive med. test not covered by insurance

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Calm Man wrote:This is a huge problem. You have been charged what I call the "crazy rate". Meaning if you look at an Explanation of Benefits for a regular covered test, like a complete blood count,k you will see something like: charged $150. Negotiated insurance rate $10. Paid by insurance $10. You owe: ZERO. So this nonsensical $4000 is probably $400 if covered maximum. That is your only hope if you are not wealthy. I would speak with the insurer and hope that they will provide you what they would pay if it were covered (they will likely say that they don't know). Then you could simply call the lab that billed you (if you got a bill, you may not have yet) and tell them you can't afford it,k you had no idea, cry a lot and see if they will cut you a break. If you get away for $100 or so, pay it right away. And you have learned something from this as have others. Thanks for sharing.
Thank you, I hope I can make this happen...
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Re: Expensive med. test not covered by insurance

Post by physicsgal »

I agree with others, call the billing office and see if you can negotiate your bill down. It may be the case that the typical negotiated rate is actually quite reasonable and they would be happy to take a much smaller amount and not have to deal with your insurance company anymore.

Healthcare is so screwed up because it's basically impossible to get the price of something before you make a decision to "purchase" it. What if you were at the store, bought some milk, and then later got a bill because they decided to charge you more for milk than the price tag? Wouldn't we consumers make a big stink? Well, that seems to be standard practice in healthcare. But most people don't care because most people never see the bills, it's only people who get denied, have HDHPs or are uninsured who get to experience this fun treatment.

My Dr. had me do a test for my kidneys last year after a blood test came out higher than she wanted. I called the office where the test was to be done and asked the price, wrote it down and kept the paper. When they billed me more than that AND I got another bill on the same procedure (radiologist bill vs hospital bill) I decided I'm just going to pay what they quoted me. They can send me to court for all I care. I'm not going to let them try to bill me whatever they feel like when they told me the price and I made a decision based on the price they told me.

Not to mention it annoyed me altogether because they sent me to get several tests and see specialist when a cheap urine test my Crossfit coach recommended would have cleared things up quickly and cheaply by showing that my kidneys are just fine thank you, which is how they eventually realized I'm perfectly healthy. What a waste of my money and time and stress/worry!
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Re: Expensive med. test not covered by insurance

Post by sscritic »

dhodson wrote:This isn't my area of expertise within medicine but I'm not seeing what or why a test was ordered. I didn't order or have ordered any such test before any of our 3 kids.
Perhaps you had no reason to, but perhaps this or something similar applies to the OP:
In Orthodox Jewish circles, the organization Dor Yeshorim carries out an anonymous screening program so that couples with Tay–Sachs or another genetic disorder can avoid conception.
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Re: Expensive med. test not covered by insurance

Post by Erwin007 »

I'm amazed that people actually think that a doctor knows or should know how much a certain test or procedure may cost a patient for something that isn't even done in their own facility or office. I see 60 patients in a day and I'm almost certain that none of them have the same insurance (same company maybe, but certainly not same level of coverage or deductible or co-insurance, or whatever). And I don't even order a lot of tests or imaging studies (xrays, MRIs, CT scans, and some occasional blood work), but for me to dedicate any brain space or mental energy on this is outlandish. Should I have some general idea about how much something costs? Probably. But to me the better answer is find out what the doctor wants ordered or done and where and then call your insurance company. It sounds like you had some time (days even) between when your doctor ordered these (elective, non-essential) tests and you could have called your insurance company, or spoken to the labs billing department about your specific insurance and cost.

I think some general transparency in cost would help, but with the thousands of variations in healthcare plans a doctor's office just doesn't have time to do all that legwork. That's what the insurance company is for. It would be like buying groceries at a store where the prices weren't marked and everyone paid a different, arbitrary amount based on what day of the year they were born on and what color car they drove and how many kids were in their family growing up.

My advice would be to let your doctor know how much it cost. He/she probably has no idea (and BTW if you think those costs are expensive, wait until you get into more fertility treatments if that route is needed) and would genuinely feel badly about how much it is costing you. I know I would feel badly about it. At the very least they will be able to better advise their patients in the future about the expected costs, and may even be able to contact the lab on your behalf and ask for a reduced charge. I also agree about calling the lab directly. For some tests there may be a lower accepted amount that insurances have contracted with them that they may authorize to charge you if you explain what happened.
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Re: Expensive med. test not covered by insurance

Post by physicsgal »

Erwin007 wrote:I'm amazed that people actually think that a doctor knows or should know how much a certain test or procedure may cost a patient for something that isn't even done in their own facility or office. I see 60 patients in a day and I'm almost certain that none of them have the same insurance (same company maybe, but certainly not same level of coverage or deductible or co-insurance, or whatever). And I don't even order a lot of tests or imaging studies (xrays, MRIs, CT scans, and some occasional blood work), but for me to dedicate any brain space or mental energy on this is outlandish. Should I have some general idea about how much something costs? Probably. But to me the better answer is find out what the doctor wants ordered or done and where and then call your insurance company. It sounds like you had some time (days even) between when your doctor ordered these (elective, non-essential) tests and you could have called your insurance company, or spoken to the labs billing department about your specific insurance and cost.

I think some general transparency in cost would help, but with the thousands of variations in healthcare plans a doctor's office just doesn't have time to do all that legwork. That's what the insurance company is for. It would be like buying groceries at a store where the prices weren't marked and everyone paid a different, arbitrary amount based on what day of the year they were born on and what color car they drove and how many kids were in their family growing up.

My advice would be to let your doctor know how much it cost. He/she probably has no idea (and BTW if you think those costs are expensive, wait until you get into more fertility treatments if that route is needed) and would genuinely feel badly about how much it is costing you. I know I would feel badly about it. At the very least they will be able to better advise their patients in the future about the expected costs, and may even be able to contact the lab on your behalf and ask for a reduced charge. I also agree about calling the lab directly. For some tests there may be a lower accepted amount that insurances have contracted with them that they may authorize to charge you if you explain what happened.
I agree it's really complicated, from what I've heard/read/experienced. But, why does it have to be so complicated? Can't we patients know the price before we make a decision, since we are the ones who have to pay the bills when they arrive? She could have called the lab and the insurance and still not have found out the price. On a different test I couldn't get a price quote ahead of time from EITHER the provider lab or from my insurance. I called both and they each said to call the other. That's just insane. How can I make a decision if it's worth the price if I can't find out the price ahead of time? Just agree to it and cross your fingers they don't decide to charge you $4000 for peeing in a cup or getting a blood test? That's what I did and I lucked out and didn't get screwed. Thank goodness!
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Re: Expensive med. test not covered by insurance

Post by mojave »

Fertility treatment is covered by my insurance.

I get that a doctor doesn't know. But it sounds like this was a very unessential test that is almost never covered by insurance unless you are x age. Surely, after 30 years of practice, she would have been aware of this? This isn't an $800 misunderstanding. This is a $4000 misunderstanding. Maybe that's not much to many people here, but that's half of our "emergency" fund. We have assets, unfortunately they are not liquid.
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Re: Expensive med. test not covered by insurance

Post by desiderium »

OP, Take a longer view on this to make the best of your situation
Don't pay anything until you have all the possibilities exhausted.
Find out who did the test and who you owe the money to. It is probably not your doctor.
If it is a large reference lab company, they will likely have discount and payment plan policies. You can almost always force them to accept payment slowly
If it is a small company offering a special or new testing package, it may have patient assistance funds.
Don't be shy about shaming your doctor's office. While doctors cant keep track of what other people charge, this is not a surprise, and they should have given you a clue. Ask them to explain the discrepancy between the $15 ballpark you were quoted and the $4000 you owe. If they have a contract with the reference lab, they may be able to intervene in your favor.
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Re: Expensive med. test not covered by insurance

Post by mojave »

desiderium wrote:OP, Take a longer view on this to make the best of your situation
Don't pay anything until you have all the possibilities exhausted.
Find out who did the test and who you owe the money to. It is probably not your doctor.
If it is a large reference lab company, they will likely have discount and payment plan policies. You can almost always force them to accept payment slowly
If it is a small company offering a special or new testing package, it may have patient assistance funds.
Don't be shy about shaming your doctor's office. While doctors cant keep track of what other people charge, this is not a surprise, and they should have given you a clue. Ask them to explain the discrepancy between the $15 ballpark you were quoted and the $4000 you owe. If they have a contract with the reference lab, they may be able to intervene in your favor.
Thank you - I will look into each and every one of those. I appreciate it.
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Re: Expensive med. test not covered by insurance

Post by Munir »

As a retired urologist, I can categorically state that your doctor's office and his staff should have known the cost of this specific test, and should have informed you at the time it was ordered. Their lack of action is unethical or demonstartes incompetence. For those apologizing for the "busy" doctor who doesn't know what each test costs- it doesn't cut it. This was no ordinary inexpensive lab test but a specialized expensive one which they should know about. No excuses.

I would write a letter to the lab who is charging you for the test, and address it to the manager of the lab. Send copoies to your doctor and to a lawyer (any lawyer friend would be OK) as cc at the bottom of the letter. Mention the sequence of events and the $15 charge the technician told you it would cost. If you don't know the name of the technician, include the date, time, and place of the drawing of the blood. Be very assertive that there was no informed consent on your part as to the prohibitive cost of the test, and politely request a major discount. Include cost of the other medical bills you have incurred lately.
Last edited by Munir on Wed Apr 09, 2014 11:38 am, edited 1 time in total.
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Re: Expensive med. test not covered by insurance

Post by EnjoyIt »

Look up the cost of this test on snaphealth.com
I'm curious what it would cost out of pocket in the free market.
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Re: Expensive med. test not covered by insurance

Post by zebrafish »

Doctors, what would you do in a situation like this? Would you alert a patient if a group of tests could potentially cost them thousands out of pocket? Does your office call their insurance if there is a concern about coverage?

I order DNA tests costing in the range of $500 to $6000+ almost every day and it is routine for me to discuss the cost of testing whether people have to pay for it or not. I think people should be aware of what things cost. This is part of the problem-- people having no idea of what things actually cost-- this is why we have a healthcare spending problem in the USA.

I think it is very poor form that the person ordered this testing w/o discussing the cost with you. I would worry that someone who did this really doesn't understand genetic testing (and when to order appropriately), either-- because it is really common knowledge among people in the field of genetics to be aware that DNA testing may not be covered in certain instances.
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Re: Expensive med. test not covered by insurance

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Re: Expensive med. test not covered by insurance

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NOLA
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Re: Expensive med. test not covered by insurance

Post by NOLA »

I feel that the doctor is partly responsible. I assume he didn't break any laws, but he should have been able to advice you, especially if he has been there for 30 years.

Good luck, hope everything turns out ok.
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Re: Expensive med. test not covered by insurance

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Jack
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Re: Expensive med. test not covered by insurance

Post by Jack »

As is typical in the U.S. medical system, you are being gouged. As indicated in this article,
http://www.nytimes.com/2013/05/21/opini ... -test.html

the true cost of genetic testing is about a nickel a gene. They could sequence all 20,000 of your genes for about $1000. But in your case they are probably testing no more than 100 genes related to possible diseases, about five bucks worth. Yet they are billing you for $4000.

This is about par for the course in U.S. medical care, the worst in the world.
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FrogPrince
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Re: Expensive med. test not covered by insurance

Post by FrogPrince »

Munir wrote:As a retired urologist, I can categorically state that your doctor's office and his staff should have known the cost of this specific test, and should have informed youat the time it was ordered. Their lack of action is unethical or demonstartes incompetence. For those apologizing for the "busy" doctor who doesn't know what each test costs- it doesn't cut it. This was no ordinary inexpensive lab test but a specialized expensive one which they should know about. No excuses.

I would write a letter to the lab who is charging you for the test, and address it to the manager of the lab. Send copoies to your doctor and to a lawyer (any lawyer friend would be OK) as cc at the bottom of the letter. Mention the sequence of events and the $15 charge the technician told you it would cost. If you don't know the name of the technician, include the date, time, and place of the drawing of the blood. Be very assertive that there was no informed consent on your part as to the prohibitive cost of the test, and politely request a major discount. Includecost of the other medical bills you have incurred lately.
Excellent advice.

In passing, I'd note that if you are with a large employer, you might be able to get your HR department to pull some strings for you. We had an unexpectedly large bill once, and they were able to get the insurer to cover it as a one-time exception.
wearymicrobe
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Re: Expensive med. test not covered by insurance

Post by wearymicrobe »

Jack wrote:As is typical in the U.S. medical system, you are being gouged. As indicated in this article,
http://www.nytimes.com/2013/05/21/opini ... -test.html

the true cost of genetic testing is about a nickel a gene. They could sequence all 20,000 of your genes for about $1000. But in your case they are probably testing no more than 100 genes related to possible diseases, about five bucks worth. Yet they are billing you for $4000.

This is about par for the course in U.S. medical care, the worst in the world.
I could solid sequence 1/3 a human genome at 4300$ with traditional outsourcing. But raw sequence is nothing without the research to back it up, but 4300$ is a huge amount of money for what should be a simple SNIP test array.
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nisiprius
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Re: Expensive med. test not covered by insurance

Post by nisiprius »

zebrafish wrote:
desiderium wrote:Unfortunately, you are most likely going to be stuck with this. These kinds of tests are not widely covered by insurance unless there are special considerations, for example a family history that would put you at high risk. Even then, it frequently requires herculean effort to get it paid by the insurance company. I think you were done a disservice by your doctors' office by not being informed of this hazard, which was probably predictable. Also, it is rare for even the most rudimentary test to cost $15, so that was a wildly inaccurate guess.
This is spot on.
No, it isn't. One person in the whole story meant well and was actually trying to be helpful, and it backfired--which shows why medical personnel are reluctant to discuss costs.

I'm looking at my Medicare claims history, and one of the items I see is:
Procedure Code 36415 - Insertion Of Needle Into Vein For Collection Of Blood Sample
Amount Charged $7.00, Medicare Approved $3.00, You May Be Billed $0.00
The payment of $2.94 was for services from [date] through [date].

I think it is at least possible that the nurse was talking about the billing rate for the blood draw itself.

I'd add that if the medical system wanted to deal with this, one obvious way to do it would be to identify "tiers" for procedures. As mojave said, this wasn't an $800 misunderstanding, it was a $4,000 misunderstanding. When you go to a restaurant guide, nobody knows what sort of meal you are likely to order, yet it is perfectly possible to make a meaningful distinction between $ and $$ and $$$.

If anyone wanted to help, it would be reasonably easy to develop a broad category system for medical procedures. Maybe ascending in factors of 3.

Level 1, under $300. Office visits.
Level 2, $300-$1,000. Complicated office visits to specialists, maybe the kind where some pictures get taken. Elaborate blood panels.
Level 3, $1,000 to $3,000. Day surgery, or colonoscopy, or MRI, or ground ambulance ride.
Level 4, $3,000 to $10,000--admitted to the hospital for a day, out the next day. Or, mojave's tests.

I don't think I want to know how much higher the scale would need go.

And the point is... "they" all know the rough order of magnitude of what things cost, but a layman really doesn't. You really don't know whether, as mojave says, you're talking $800 or $4,000.
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synpacket
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Re: Expensive med. test not covered by insurance

Post by synpacket »

Sorry to hear this happened, I hope you can somehow get the cost reduced. This kind of thing scares me. Even though I have insurance, I'm fairly young and still of the mindset that I just better never get sick or need to see a doctor. Our system is [messed up --admin LadyGeek].
desiderium
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Re: Expensive med. test not covered by insurance

Post by desiderium »

nisiprius wrote:No, it isn't. One person in the whole story meant well and was actually trying to be helpful, and it backfired--which shows why medical personnel are reluctant to discuss costs.
This is a charitable comment. The medical economy is byzantine and medical costs are the leading reason for personal bankruptcy. The financial hazards faced by the OP arise in every practice every day. In reality, helping to keep patients solvent can be a necessary part of successful treatment. Physicians are not in a position to keep track of everything health insurers are doing. Still, helping to manage financial issues is now part of the practice of medicine.
Mitchell777
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Re: Expensive med. test not covered by insurance

Post by Mitchell777 »

I agree. Call the lab and negotiate. You could also call a couple other labs and get quotes. Keep in mid that the lab that drew the blood may not be the lab that performed the test. These are esoteric type tests that may well be outsourced to one of the major national labs. That may mean the negotiation will be a bit harder. The incremental cost of the test may be nowhere near the price you paid. The lab however, if a major lab, may have hundreds of MD's and PhD's behind their testing so the cost of running the test is not their only cost. Also the lab is probably paying a fee to the company that developed the test. Sorry, I know it is not a simple thing to negotiate and you should have been told up front. My doctor ordered a genenic test for me recently and he told it would be costly. Good luck
Jfet
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Re: Expensive med. test not covered by insurance

Post by Jfet »

Jack wrote:As is typical in the U.S. medical system, you are being gouged. As indicated in this article,
http://www.nytimes.com/2013/05/21/opini ... -test.html

the true cost of genetic testing is about a nickel a gene. They could sequence all 20,000 of your genes for about $1000. But in your case they are probably testing no more than 100 genes related to possible diseases, about five bucks worth. Yet they are billing you for $4000.

This is about par for the course in U.S. medical care, the worst in the world.
$5 huh?

The sample has to be shipped to the testing facility, handled by a technician, who is probably under management, there are secretaries, insurance costs for malpractice, reports to be generated, disposal costs of the blood/urine and container.

If all of that is contained in the $5 I would hate to be the manufacturer that actually provides the DNA testing equipment to this company. It must be crazy trying to argue the price of the DNA sequencer down to $100.
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mojave
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Re: Expensive med. test not covered by insurance

Post by mojave »

For those that know about this type of testing, I was tested for fragile x, cystic fibrosis, down syndrome (I think, don't have the papers on hand) and I think one or two others. It wasn't a test that does 100+ screenings.

Also, I just remembered I had them do testing on my immune system and thyroid because I had some concerns about that with some issues I've been having, but those tests only amount to a few dollars.

Sorry, my mind has not been clear the last few days. The immune tests were covered by insurance, thyroid wasn't for whatever reason but it isn't that much. Sorry for any confusion about my original price.

Here is what my EOB looks like:

NOT COVERED BY INSURANCE (I did get a PPO discount apparently, which is even more frightening in the grand scheme of things)

Name of Test Out of Pocket Cost [PPO Discount]

CFTY Gene Com Varients $700 [$4045]
Molecular Pathology Interp $24 [$81]
Thyroxine; Free $8 [$92]
FMR1 Gene Detection $954 [$0]
Mopath Procedure Level 2 $2550 [$850]

COVERED BY INSURANCE

Routine venipunct/finger/heel stick-collc specm
$2
Antib; Rubella $2.60
Antib; Varicella-Zoster $2.40

And yes, I am immune to Rubella and the Chicken Pox :happy
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Re: Expensive med. test not covered by insurance

Post by Random Musings »

I think every patient should ask for pricing before proceding with various medical cares (except for dire emergencies, where time is of the essence). They also should check to see if they have insurance coverage.

However, I find it lacking if a doctor doesn't convey to their patients an idea of what costs are involved with more expensive procedures/testing. If they don't know, they should find out. However, it is still up to the patient to see if their insurance covers what is being recommended.

In the past 3 years, a family member had genetic testing and was informed by the specialist about potential costs and was also provided a number to the lab that would perform that analysis. The insurance company was contacted and then everyone was on the same page so that a rational decision could be made.

RM
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Rupert
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Re: Expensive med. test not covered by insurance

Post by Rupert »

I carry a copy of my health insurance contract with me to every doctor's appointment. Any time a procedure is recommended by one of my providers, I actually whip out my contract while I'm in the doctor's office and make the insurance person verify the out-of-pocket cost to me while I'm sitting in front of him/her. As consumers in this insane system, we've got to be proactive.
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Re: Expensive med. test not covered by insurance

Post by mojave »

Also re: me checking insurance.

Now that my mind is a little clearer, I remember that I did check our summary plan description book (after my husband was hospitalized with Meningitis, and I had to battle our insurance for some coverage of that, this book and I became close friends).

In my ignorance about gene testing and insurance, I was under the impression that my test fell under one of the categories:

"Genetic Testing to the extent required under the Affordable Care Act" 100% covered
"Amniotic Fluid or Genomic/Oncotype Testing" 80% covered (I am guessing this is what I thought I was getting)
"Gene Expression Profiling to Determine a Treatment Plan for a Cancer Diagnosis" 80% covered

HOWEVER.

20 pages later there is this, which I found after this fiasco came into my mailbox:

Genetic Testing
The Plan covers genetic testing for gene expression profiling to determine cancer treatment and genetic testing on amniotic fluid. The Plan does not cover genetic testing to identify a potential illness or a potential genetic disorder, except to the extent required under the Affordable Care Act.
Last edited by mojave on Wed Apr 09, 2014 12:04 pm, edited 1 time in total.
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Re: Expensive med. test not covered by insurance

Post by mojave »

Rupert wrote:I carry a copy of my health insurance contract with me to every doctor's appointment. Any time a procedure is recommended by one of my providers, I actually whip out my contract while I'm in the doctor's office and make the insurance person verify the out-of-pocket cost to me while I'm sitting in front of him/her. As consumers in this insane system, we've got to be proactive.
This is a really good idea. I think I will do this as well.
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Re: Expensive med. test not covered by insurance

Post by Munir »

mojave, you have received a lot of advice on this forum. Have you decided yet on a course of action?
Jack
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Re: Expensive med. test not covered by insurance

Post by Jack »

Jfet wrote:$5 huh?

The sample has to be shipped to the testing facility, handled by a technician, who is probably under management, there are secretaries, insurance costs for malpractice, reports to be generated, disposal costs of the blood/urine and container.

If all of that is contained in the $5 I would hate to be the manufacturer that actually provides the DNA testing equipment to this company. It must be crazy trying to argue the price of the DNA sequencer down to $100.
If the actual sequencing costs just a few dollars but the overhead is $4000, that is one horribly messed up medical system.

The technology improvement of DNA sequencers is much like the improvements in silicon chip design -- the cost has been cut in half every two years for the last couple of decades. A DNA sequencer costs $10,000 to $20,000.

The National Institute of Health's Human Genome Project estimated last year that sequencing the entire genome, about 20,000 genes, costs a few thousand dollars. That is the all-in price -- labor, administration, management, reagents and amortization of equipment. Costs have come down since then.

A screen for 100 genes is just a few dollars.

https://www.genome.gov/sequencingcosts/
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Re: Expensive med. test not covered by insurance

Post by Jfet »

Jack wrote: If the actual sequencing costs just a few dollars but the overhead is $4000, that is one horribly messed up medical system.

The technology improvement of DNA sequencers is much like the improvements in silicon chip design -- the cost has been cut in half every two years for the last couple of decades. A DNA sequencer costs $10,000 to $20,000.

The National Institute of Health's Human Genome Project estimated last year that sequencing the entire genome, about 20,000 genes, costs a few thousand dollars. That is the all-in price -- labor, administration, management, reagents and amortization of equipment. Costs have come down since then.

A screen for 100 genes is just a few dollars.

https://www.genome.gov/sequencingcosts/
$4000 is definitely not the overhead but there is no chance the overhead can be contained in $5.

Perhaps $100 to $200 might be a reasonable cost including overhead, transportation, administration, malpractice insurance

It would be like me saying the cost of transistors on a chip has come down to $0.0001 so why can't I get a 5000 transistor ASIC delivered to me for $5?
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Re: Expensive med. test not covered by insurance

Post by mojave »

Munir wrote:mojave, you have received a lot of advice on this forum. Have you decided yet on a course of action?
I sent a diplomatic email to my Dr first to see what she says. I want it in writing, which is why I went the email route. I explained how I was upset by this situation and basically reiterated my initial post, asking if they have a solution in mind. I have not heard anything back yet. She usually makes phone calls after hours, so if she calls me it will be later tonight.

Next I will talk to insurance and see what they have to say, but I don't think anything will happen this route. I'll try an appeal but again, I don't expect anything from that.

If I can't get any support or relief from the above two avenues, I will contact the genetic testing company. If that doesn't work, I'll be taking the advice to go directly to the billing Manager or Director, with a letter explaining what happened and providing copies of the other bills I have to pay off. If that doesn't work, I'll see if there's anyone else there I can find that might have the ability to help if they are so inclined.

If THAT doesn't work, I will look into any support or programs the state offers.

If nothing works at all, my mom has offered to help me with roughly half of it with the caveat that I can pay her back if I win the lottery (her way of saying, I don't expect to see it again and I am doing this to help you). I did not ask for this and I don't even want it but she is insisting on it. And then I guess, just add it to every other medical bill we're trying to get rid of.
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Re: Expensive med. test not covered by insurance

Post by zebrafish »

CFTY Gene Com Varients $700 [$4045]
Molecular Pathology Interp $24 [$81]
Thyroxine; Free $8 [$92]
FMR1 Gene Detection $954 [$0]
Mopath Procedure Level 2 $2550 [$850]


This is somewhat helpful.
CFTR genotyping should cost maybe ~$200-400; $700 is expensive, $4045 is ridiculous
FMR1 Gene detection should cost maybe ~$300; $954 is high

I am not that familiar with procedure billing/coding for molecular pathology, but the above pricing would include interpretation. Thus, $850/$2550 is very high.

These tests are very common and so they are done by virtually all molecular pathology labs. CFTR testing of some sort (typically a mutation panel) is recommended by the American College of Obstetrics & Gynecology ("ACOG") for all pregnant women, so I'm surprised that this isn't covered. It doesn't appear like the OB/GYN ordered anything really unusual-- these are considered pretty standard lab tests that are relatively common. The problem is on the insurance/coverage/billing/charge side...

Cost of Fragile X testing is discussed:
http://www.fragilex.org/fragile-x-assoc ... s/testing/

CFTR mutation panel testing by this lab is pretty reasonable cost:
http://www.ggc.org/diagnostic/tests-cos ... panel.html

You can find other labs by going onto this website:
www.genetests.org

The websites I quote are reasonable price. Many others charge similar prices. You could probably negotiate based on prices from other labs.
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Re: Expensive med. test not covered by insurance

Post by mojave »

zebrafish wrote:CFTY Gene Com Varients $700 [$4045]
Molecular Pathology Interp $24 [$81]
Thyroxine; Free $8 [$92]
FMR1 Gene Detection $954 [$0]
Mopath Procedure Level 2 $2550 [$850]


This is somewhat helpful.
CFTR genotyping should cost maybe ~$200-400; $700 is expensive, $4045 is ridiculous
FMR1 Gene detection should cost maybe ~$300; $954 is high

I am not that familiar with procedure billing/coding for molecular pathology, but the above pricing would include interpretation. Thus, $850/$2550 is very high.

These tests are very common and so they are done by virtually all molecular pathology labs. CFTR testing of some sort (typically a mutation panel) is recommended by the American College of Obstetrics & Gynecology ("ACOG") for all pregnant women, so I'm surprised that this isn't covered. It doesn't appear like the OB/GYN ordered anything really unusual-- these are considered pretty standard lab tests that are relatively common. The problem is on the insurance/coverage/billing/charge side...

Cost of Fragile X testing is discussed:
http://www.fragilex.org/fragile-x-assoc ... s/testing/

CFTR mutation panel testing by this lab is pretty reasonable cost:
http://www.ggc.org/diagnostic/tests-cos ... panel.html

You can find other labs by going onto this website:
http://www.genetests.org

The websites I quote are reasonable price. Many others charge similar prices. You could probably negotiate based on prices from other labs.
Thank you so much!!
mur44
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Re: Expensive med. test not covered by insurance

Post by mur44 »

This is a situation that warrants your negotiating with
the service provider directly.

Tell them that you can NOT afford.

There are medical bill negotiators that you can
search online to help you with negotiation.
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