Not allowed to do testing/imaging outside hospital network

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sawhorse
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Not allowed to do testing/imaging outside hospital network

Post by sawhorse »

I see some physicians in a large hospital/healthcare network. I need to periodically get blood tests in order to continue to use a medication. The doctor won't refill the prescription without seeing the test results.

I used to be able to get the tests done at a lab more convenient for me, and I could also go to the Quest office and have them done there. It saved me money on the copay and probably saved my insurance some money too.

Now I am required to use a lab in the hospital network. They won't accept test results from elsewhere, so I have no choice if I want to get the prescription renewed.

I also recently had to have a scan. There are independent imaging centers that cost less, but again they would only accept results from an imaging center in their network. I couldn't have a follow-up appointment until I had a scan from within their network.

The doctor determined that I need surgery, and they require a negative coronavirus test three days before. Again, they will only accept results from one of their testing sites. None of them are drive through or outdoors. I'm afraid of catching the virus inside a testing facility, so I'd really like to go to a clinic with drive through testing.

Being limited to testing facilities in the network has cost me substantial money as my copay is lower for some facilities outside the network, and I'm sure it saves my insurance company money too. Now with coronavirus, it has presented a safety concern too.

Is there anything I can do to get them to accept results from outside their network?

Edit for clarification: This involves multiple doctors who all changed their policy to not accept outside results. I'm almost certain the individual doctors did not make the decision but rather were told from someone higher.
Last edited by sawhorse on Sat Sep 19, 2020 2:25 pm, edited 1 time in total.
egrets
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Re: Not allowed to do testing/imaging outside hospital network

Post by egrets »

This seems bizarre. One often hears of medical insurance not paying for out of network stuff, but I never heard of a place not using outside results.

Are you sure that's what's happening? What hospital network is this?
Last edited by egrets on Sat Sep 19, 2020 5:26 am, edited 1 time in total.
Mr. Rumples
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Re: Not allowed to do testing/imaging outside hospital network

Post by Mr. Rumples »

I can understand that they want their own Covid test. I know two people who have had two tests, the first positive and the second negative on each person from a CVS location.

Other than change providers, you are, in most states, stuck. My physician "prefers" to have MRI's done in network. I understand why in a way. I had an MRI of my foot done by a stand alone location and they left off the end third! (They opened it up for me on a Saturday to come back in.) But in the way, its about the $ and not the patient.
dcabler
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Re: Not allowed to do testing/imaging outside hospital network

Post by dcabler »

sawhorse wrote: Sat Sep 19, 2020 4:46 am I see some physicians in a large hospital/healthcare network. I need to periodically get blood tests in order to continue to use a medication. The doctor won't refill the prescription without seeing the test results.

I used to be able to get the tests done at a lab more convenient for me, and I could also go to the Quest office and have them done there. It saved me money on the copay and probably saved my insurance some money too.

Now I am required to use a lab in the hospital network. They won't accept test results from elsewhere, so I have no choice if I want to get the prescription renewed.

I also recently had to have a scan. There are independent imaging centers that cost less, but again they would only accept results from an imaging center in their network. I couldn't have a follow-up appointment until I had a scan from within their network.

The doctor determined that I need surgery, and they require a negative coronavirus test three days before. Again, they will only accept results from one of their testing sites. None of them are drive through or outdoors. I'm afraid of catching the virus inside a testing facility, so I'd really like to go to a clinic with drive through testing.

Being limited to testing facilities in the network has cost me substantial money as my copay is lower for some facilities outside the network, and I'm sure it saves my insurance company money too. Now with coronavirus, it has presented a safety concern too.

Is there anything I can do to get them to accept results from outside their network?
How tied are you to this physician? Perhaps find another in-network physician without the restrictions?

Cheers
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whodidntante
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Re: Not allowed to do testing/imaging outside hospital network

Post by whodidntante »

Ask why. See if you agree.

Ask who can change the decision. Talk to that person. It's probably not your peon doctor, but maybe it is. Talk to top administrators if the person informing you of the restriction does not seem to know.

Decide now what the consequences are going to be if they do not modify their behavior. Are you willing and able to leave your doctor and steer clear of that hospital network over this? Or are you making a polite request?
scifilover
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Re: Not allowed to do testing/imaging outside hospital network

Post by scifilover »

This kind of thing can happen with HMO style plans especially when the plan is run by the clinic/hospital system. When the provider can provide all medical care, including labs, scans, primary care, specialist care, surgery etc., they are most efficient when everything stays within the system. When anything is done outside the system and the record of that work is submitted, someone in the system has to get it into the computerized records before the information is usable inside the system. Generally, the HMO style plan takes this efficiency in mind when they price their plan. The lack of an industry standardized record format for medical care creates these kinds of issues.....Kaiser is a good example...
Marylander1
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Re: Not allowed to do testing/imaging outside hospital network

Post by Marylander1 »

My physicians have some restrictions, and explained why in terms I agree with. My physicians are fine with lab results from anywhere, as their complete results can be provided in a few pages of text. For imaging, they rightfully insist on receiving high-quality images—not a text summary written by a radiologist. This is easy in-network, but for out-of-network I have to bring a disc or otherwise arrange to get the images delivered to the physician.

They also announced for Covid-19 testing before a procedure, they require their own in-network test because there are many different tests and ways of administering them.

Marylander1
InMyDreams
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Re: Not allowed to do testing/imaging outside hospital network

Post by InMyDreams »

I've always understood that patient's have the right to choose the providers for lab work and treatments...that a physician requiring you to obtain services from particular providers was a potential conflict of interest... talk to patient relations or a state regulator. Things do change, and I'm not certain. There's also that uncomfortable margin of going against your physician's directions.
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btq96r
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Re: Not allowed to do testing/imaging outside hospital network

Post by btq96r »

sawhorse wrote: Sat Sep 19, 2020 4:46 am I also recently had to have a scan. There are independent imaging centers that cost less, but again they would only accept results from an imaging center in their network. I couldn't have a follow-up appointment until I had a scan from within their network.
I can't speak to the labs, but I work in the radiology business, so I can opine on this part.

There is no logical reason for them to restrict your imaging in their network other than keeping your money in the system. Sometimes a surgeon likes to have the radiologist they know in the hospital to consult on the images with, but that's a convenience, not a requirement. It might be on you as the patient to get the images and report done at the independent imaging center on a disc for them, but any imaging center should be able to provide that for you, and that physician at the hospital can then give it to their local PACS admin to upload it on their systems. The only scans you should need in their network are ones done as part of an procedure you're having done in the hospital such as image guided biopsies, or the check before someone is closed up after surgery to see if anything out of order was left inside you.

I can't help but feel the system is trying to keep your services under their wing for financial benefit. Recommending the ease of the physician network for a smoother clinical flow is one thing, saying they won't accept results from a licensed imaging center is another. It's crap like this that invites over-regulation of the medical system costing everyone money in the long run. Tell these people to pound sand and get the best care at a price point you are comfortable with.
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sawhorse
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Re: Not allowed to do testing/imaging outside hospital network

Post by sawhorse »

scifilover wrote: Sat Sep 19, 2020 7:31 am This kind of thing can happen with HMO style plans especially when the plan is run by the clinic/hospital system. When the provider can provide all medical care, including labs, scans, primary care, specialist care, surgery etc., they are most efficient when everything stays within the system. When anything is done outside the system and the record of that work is submitted, someone in the system has to get it into the computerized records before the information is usable inside the system. Generally, the HMO style plan takes this efficiency in mind when they price their plan. The lack of an industry standardized record format for medical care creates these kinds of issues.....Kaiser is a good example...
I have a PPO. I'm allowed to go to other testing places under my plan. But the issue is that the doctors won't accept results from outside their hospital network.
InMyDreams wrote: Sat Sep 19, 2020 12:01 pm I've always understood that patient's have the right to choose the providers for lab work and treatments...that a physician requiring you to obtain services from particular providers was a potential conflict of interest... talk to patient relations or a state regulator. Things do change, and I'm not certain. There's also that uncomfortable margin of going against your physician's directions.
My guess is that the directive came from the top. It sure didn't come from the individual doctors as I can't imagine they would all simultaneously make this change in policy individually.
Mudpuppy
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Re: Not allowed to do testing/imaging outside hospital network

Post by Mudpuppy »

sawhorse wrote: Sat Sep 19, 2020 4:46 am Edit for clarification: This involves multiple doctors who all changed their policy to not accept outside results. I'm almost certain the individual doctors did not make the decision but rather were told from someone higher.
You've probably hit the nail on the head here. Their bosses are probably telling them to do this and they likely don't want to risk their jobs telling their bosses no. It's actually a pretty shaky job market for physicians right now, so I can fully understand their reluctance to protest the new policy.

You should check into your patient rights, as afforded by your state and local regulations, to see if this sort of policy is allowed in your state. If it is not allowed by your state or local regulations, complain directly to the appropriate state / local agency. If it is allowed by your state / local regulations, you could try getting the insurance company involved. They may not like one of their approved networks having a policy that increases the costs to the insurance company. The threat of getting dropped by the insurance company might be enough to get the bosses to back off, assuming the insurance company takes it to that phase (they might not).

But if it is allowed by regulations or if either complaint route will take too long to resolve for your particular care needs, you'll also have to consider if this policy will be enough to motivate you to switch doctors to ones without such a policy.
nydoc
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Re: Not allowed to do testing/imaging outside hospital network

Post by nydoc »

No physician will jeopardize their employment by fighting for this issue as this issue doesn’t translate into inferior care. They will treat you to the best of their ability but beyond that they are also interested in their job and finances like you. You should complain to hospital CEO or state Dept of health. Sadly physicians have no role in how healthcare is run these days.
IMO
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Re: Not allowed to do testing/imaging outside hospital network

Post by IMO »

btq96r wrote: Sat Sep 19, 2020 12:09 pm
sawhorse wrote: Sat Sep 19, 2020 4:46 am I also recently had to have a scan. There are independent imaging centers that cost less, but again they would only accept results from an imaging center in their network. I couldn't have a follow-up appointment until I had a scan from within their network.
I can't speak to the labs, but I work in the radiology business, so I can opine on this part.

There is no logical reason for them to restrict your imaging in their network other than keeping your money in the system. Sometimes a surgeon likes to have the radiologist they know in the hospital to consult on the images with, but that's a convenience, not a requirement. It might be on you as the patient to get the images and report done at the independent imaging center on a disc for them, but any imaging center should be able to provide that for you, and that physician at the hospital can then give it to their local PACS admin to upload it on their systems. The only scans you should need in their network are ones done as part of an procedure you're having done in the hospital such as image guided biopsies, or the check before someone is closed up after surgery to see if anything out of order was left inside you.

I can't help but feel the system is trying to keep your services under their wing for financial benefit. Recommending the ease of the physician network for a smoother clinical flow is one thing, saying they won't accept results from a licensed imaging center is another. It's crap like this that invites over-regulation of the medical system costing everyone money in the long run. Tell these people to pound sand and get the best care at a price point you are comfortable with.
Agree. Even if a particular facility (lab/imaging) has some connectivity for convenience, it makes no logical sense that one can't provide or get lab/images at a facility that is more cost effective for a patient.

If your an AZ, you can order/pay for your own lab tests. You don't have to make an argument to your provider if why you may personally want to have a given lab ordered that a provider would have to "justify."

Example link for Arizona Labs:
https://www.sonoraquest.com/
Notsobad
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Re: Not allowed to do testing/imaging outside hospital network

Post by Notsobad »

This is horrible. I know of physicians who are penalized if referrals go out of the system, but it really the next level of greed to make a policy to stop accepting outside results.

Complain to your health plan. If it costs you more money likely it is costing them more money.
InMyDreams
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Re: Not allowed to do testing/imaging outside hospital network

Post by InMyDreams »

Mudpuppy wrote: Sat Sep 19, 2020 2:35 pm
You should check into your patient rights, as afforded by your state and local regulations, to see if this sort of policy is allowed in your state. If it is not allowed by your state or local regulations, complain directly to the appropriate state / local agency. If it is allowed by your state / local regulations, you could try getting the insurance company involved. They may not like one of their approved networks having a policy that increases the costs to the insurance company.
This.
Having worked in a clinic that was in competition with doctors' offices to provide treatment...
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celia
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Re: Not allowed to do testing/imaging outside hospital network

Post by celia »

Who is "they" that is "requiring" the location? If you are an in-hospital patient, I would expect only hospital labs and scans could be provided. But if you are seeing a doctor in an office setting, she usually won't have this restriction. And larger professional buildings (containing doctor offices) often have a lab or imaging service in the building as a convenience, but you aren't limited to using them.

I think you should ask "why" to whomever says it is "required".
UpperNwGuy
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Re: Not allowed to do testing/imaging outside hospital network

Post by UpperNwGuy »

Time to find a new doctor.
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sawhorse
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Re: Not allowed to do testing/imaging outside hospital network

Post by sawhorse »

celia wrote: Sat Sep 19, 2020 6:00 pm Who is "they" that is "requiring" the location? If you are an in-hospital patient, I would expect only hospital labs and scans could be provided. But if you are seeing a doctor in an office setting, she usually won't have this restriction. And larger professional buildings (containing doctor offices) often have a lab or imaging service in the building as a convenience, but you aren't limited to using them.

I think you should ask "why" to whomever says it is "required".
The doctors are inside a large complex that has a lot of medical offices as well as a hospital.
UpperNwGuy wrote: Sat Sep 19, 2020 6:17 pm Time to find a new doctor.
It would be impractical to replace all my doctors in this network. I have a rare condition, and this is a large center affiliated with a top medical school. Plus, who knows how long it would take to get an appointment with doctors at another network, and who's to say they won't have the same requirement. Even if they don't at this time, they might implement it in the near future seeing how their rival hospital network has gotten away with it.
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celia
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Re: Not allowed to do testing/imaging outside hospital network

Post by celia »

sawhorse wrote: Sat Sep 19, 2020 6:27 pm
celia wrote: Sat Sep 19, 2020 6:00 pm Who is "they" that is "requiring" the location? If you are an in-hospital patient, I would expect only hospital labs and scans could be provided. But if you are seeing a doctor in an office setting, she usually won't have this restriction. And larger professional buildings (containing doctor offices) often have a lab or imaging service in the building as a convenience, but you aren't limited to using them.

I think you should ask "why" to whomever says it is "required".
The doctors are inside a large complex that has a lot of medical offices as well as a hospital.
What about a patient who drives 100 miles to see a specialist there? I don't see how they can be required to have all their "between-appointments" labs there, too. See if they have a Patient Advocate there who represents the patients and give them a call.
UpperNwGuy
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Re: Not allowed to do testing/imaging outside hospital network

Post by UpperNwGuy »

sawhorse wrote: Sat Sep 19, 2020 6:27 pm
celia wrote: Sat Sep 19, 2020 6:00 pm Who is "they" that is "requiring" the location? If you are an in-hospital patient, I would expect only hospital labs and scans could be provided. But if you are seeing a doctor in an office setting, she usually won't have this restriction. And larger professional buildings (containing doctor offices) often have a lab or imaging service in the building as a convenience, but you aren't limited to using them.

I think you should ask "why" to whomever says it is "required".
The doctors are inside a large complex that has a lot of medical offices as well as a hospital.
UpperNwGuy wrote: Sat Sep 19, 2020 6:17 pm Time to find a new doctor.
It would be impractical to replace all my doctors in this network. I have a rare condition, and this is a large center affiliated with a top medical school. Plus, who knows how long it would take to get an appointment with doctors at another network, and who's to say they won't have the same requirement. Even if they don't at this time, they might implement it in the near future seeing how their rival hospital network has gotten away with it.
It sounds like your doctors are part of Mayo Clinic, Johns Hopkins, Cleveland Clinic, or one of the other nationally-known, high-cost, research-oriented medical communities. The sad truth is that these networks play by different rules, and they can get away with it because they are really good at what they do, and patients with serious problems are often willing to fly across country to receive the care. Costs of such centers are high, so they make rules to ensure that patients don't cherry-pick their services and go elsewhere for less expensive, more routine testing.
toofache32
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Re: Not allowed to do testing/imaging outside hospital network

Post by toofache32 »

btq96r wrote: Sat Sep 19, 2020 12:09 pm
sawhorse wrote: Sat Sep 19, 2020 4:46 am I also recently had to have a scan. There are independent imaging centers that cost less, but again they would only accept results from an imaging center in their network. I couldn't have a follow-up appointment until I had a scan from within their network.
There is no logical reason for them to restrict your imaging in their network other than keeping your money in the system.
As a surgeon who sees patients from across my state and surrounding states, I can attest that not all imaging is the same. I have learned which local facilities routinely provide high quality imaging and which don't. I tell these patients we can schedule the imaging back home but if it is inadequate then they will have to travel and have it repeated at one of my trusted local facilities.
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Picasso
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Re: Not allowed to do testing/imaging outside hospital network

Post by Picasso »

sawhorse wrote: Sat Sep 19, 2020 2:20 pm
scifilover wrote: Sat Sep 19, 2020 7:31 am This kind of thing can happen with HMO style plans especially when the plan is run by the clinic/hospital system. When the provider can provide all medical care, including labs, scans, primary care, specialist care, surgery etc., they are most efficient when everything stays within the system. When anything is done outside the system and the record of that work is submitted, someone in the system has to get it into the computerized records before the information is usable inside the system. Generally, the HMO style plan takes this efficiency in mind when they price their plan. The lack of an industry standardized record format for medical care creates these kinds of issues.....Kaiser is a good example...
I have a PPO. I'm allowed to go to other testing places under my plan. But the issue is that the doctors won't accept results from outside their hospital network.
InMyDreams wrote: Sat Sep 19, 2020 12:01 pm I've always understood that patient's have the right to choose the providers for lab work and treatments...that a physician requiring you to obtain services from particular providers was a potential conflict of interest... talk to patient relations or a state regulator. Things do change, and I'm not certain. There's also that uncomfortable margin of going against your physician's directions.
My guess is that the directive came from the top. It sure didn't come from the individual doctors as I can't imagine they would all simultaneously make this change in policy individually.
Health insurance industry guy here.

The hospital system is trying to keep revenue all in house and for a PPO plan this is highly unusual and may even be violating contract provisions they have with your insurance company. Providers are under stress right now from lost revenue due to Covid-19.

This practice is raising costs for everyone which will impact member experience. You should alert your insurance provider, which will want to have a firm talk with the provider organization.
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btq96r
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Re: Not allowed to do testing/imaging outside hospital network

Post by btq96r »

toofache32 wrote: Sat Sep 19, 2020 10:57 pm As a surgeon who sees patients from across my state and surrounding states, I can attest that not all imaging is the same. I have learned which local facilities routinely provide high quality imaging and which don't. I tell these patients we can schedule the imaging back home but if it is inadequate then they will have to travel and have it repeated at one of my trusted local facilities.
I get that the imaging is different by site because of issues like scanner quality, tech competence, even radiologist impressions...but the reasons being given to the patient in this case just don't add up. If they had come to them and said, "we really want you to get your scans done in the hospital so the quality is good and surgeon can consult with the radiologist pre-surgery because that will give you the best outcome", I would think that's on the up and up, and probably worth the added cost. But they seem to be getting the patient steering end-around, and that's unsat.

If we're talking a simple study, and there isn't a clinically significant difference in quality of the images, both the images and report can be put on a disk and uploaded locally. If the radiologist has to give a full overread or dictate a second report for clarity or to correct a miss, they can put that under a special CPT code for overreads/2nd opinions to generate a charge...just need to state why it's being done in the clinical history so the coders can take it from there.

When the technical fee of an imaging study comes out to about 75-80% of the total bill, that's worth looking into alternatives for cost savings on.
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