Medical Billing, is this typical?

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Topic Author
JHU ALmuni
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Medical Billing, is this typical?

Post by JHU ALmuni » Wed Jan 08, 2020 9:59 am

I recently started a new job and got new insurance so I scheduled an appointment with a new doctor for my annual physical. I went to the clinic not complaining from anything and the doctor ordered blood test (as usual), EKG, chest xray, sonogram on my pelvic, legs, and neck before he even see me. I thought this is how the annual physical is performed in NY (recently moved from another state) and did not ask any questions if these tests are included in my annual physical benefits or I will pay for it out of pocket. :oops:

Today I got my EOB letter and basically I need to pay close to $700 for these tests. Again I was there only for my annual physical and not complaining from anything. Usually these visits cost me $0 to $20 (if the doctor adds anything to the blood test) but to see a $700 is something I wasn't expecting.

How should I handle this? I know I should asked more questions but I didn't. Nothing similar to this happened before and considering I wasn't complaining from anything I though this is how annual physical is done here for a 36 years old male.

CascadiaSoonish
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Re: Medical Billing, is this typical?

Post by CascadiaSoonish » Wed Jan 08, 2020 10:13 am

I'm not a physician, but I've never heard of a routine physical including a chest x-ray for an otherwise healthy 30-something. If I were you I'd be talking to the doctor's office to find out what they're looking for here.

njuser
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Re: Medical Billing, is this typical?

Post by njuser » Wed Jan 08, 2020 10:16 am

That is not typical.

Insurance is telling you what you are responsible for via the EOB; they are not judging whether a test is or is not appropriate. Look at each charge and see why it was charged. Here is a list of preventative services which should be included in your 'annual physical'. It is quite limited: https://www.healthcare.gov/preventive-care-adults/

When you are at your annual physical, if you do not want to pay for 'extra services', it is best to limit your questions. If you ask about any pains, symptoms, etc. it then becomes a diagnostic visit, for which your deductible/coinsurance will apply.

If it was me, I would go back and complain to the doctor's office. Tell them that you booked an annual physical, not a diagnostic visit. Ask them why they required all these tests for a well check. If they are not helpful, tell them that you are going to follow up with a formal complaint to your state's insurance department.

If they are not cooperative, your next move would be to write a letter of complaint to your state's insurance department. There is a 'file a complaint' button on this page https://www.dfs.ny.gov/consumers/health ... e_consumer

I would not pay these bills until you have contacted both the doctor's office and your state department of insurance. There is usually a time limit to file a complaint so be prompt. I have written my department of insurance in NJ and they answered fairly promptly (2 weeks) and were helpful.

Good luck. In the future, refer to your insurance company's summary of benefits before you get any tests done so you know what you would be covered for. Also question your doctor as to why you need each test. If you don't agree, seek a second opinion or refuse the test.

If none of this works, your last resort is to call each provider's billing department and try to negotiate a discount.

Mr. Rumples
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Re: Medical Billing, is this typical?

Post by Mr. Rumples » Wed Jan 08, 2020 10:27 am

You can also file a complaint with the NY board of medicine if you don't get an adequate response. You may also request your medical records which should indicate why such tests were ordered in the first place. The cost is limited to $0.75 per page so its cheap. Don't know about NY, but in VA the law is very clear that a physician cannot withhold medical records until a medical bill is paid, but they may require prepayment for the records.

As mentioned above, pay attention to time limits and document everything, every call, every name.

https://lac.org/wp-content/uploads/2014 ... t_form.pdf

chessknt
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Re: Medical Billing, is this typical?

Post by chessknt » Wed Jan 08, 2020 10:32 am

I agree that, as described, this is unusual.

See what diagnoses were billed and what the justification was for these tests since it might not be inappropriate. Upper and lower extremity vein ultrasound is hard to justify without a complaint and sight unseen however...

If these were done in the physicians office then it was likely highly inappropriate.

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JHU ALmuni
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Re: Medical Billing, is this typical?

Post by JHU ALmuni » Wed Jan 08, 2020 11:38 am

njuser wrote:
Wed Jan 08, 2020 10:16 am
That is not typical.

Insurance is telling you what you are responsible for via the EOB; they are not judging whether a test is or is not appropriate. Look at each charge and see why it was charged. Here is a list of preventative services which should be included in your 'annual physical'. It is quite limited: https://www.healthcare.gov/preventive-care-adults/

When you are at your annual physical, if you do not want to pay for 'extra services', it is best to limit your questions. If you ask about any pains, symptoms, etc. it then becomes a diagnostic visit, for which your deductible/coinsurance will apply.

If it was me, I would go back and complain to the doctor's office. Tell them that you booked an annual physical, not a diagnostic visit. Ask them why they required all these tests for a well check. If they are not helpful, tell them that you are going to follow up with a formal complaint to your state's insurance department.

If they are not cooperative, your next move would be to write a letter of complaint to your state's insurance department. There is a 'file a complaint' button on this page https://www.dfs.ny.gov/consumers/health ... e_consumer

I would not pay these bills until you have contacted both the doctor's office and your state department of insurance. There is usually a time limit to file a complaint so be prompt. I have written my department of insurance in NJ and they answered fairly promptly (2 weeks) and were helpful.

Good luck. In the future, refer to your insurance company's summary of benefits before you get any tests done so you know what you would be covered for. Also question your doctor as to why you need each test. If you don't agree, seek a second opinion or refuse the test.

If none of this works, your last resort is to call each provider's billing department and try to negotiate a discount.
Thank you for the information. The issue is mainly with the Dr. Office not the insurance company. I haven't met my deductible so this is why I need to pay out of pocket for these extra tests. In this case can I still file a complaint with state department of insurance?

sailaway
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Re: Medical Billing, is this typical?

Post by sailaway » Wed Jan 08, 2020 11:40 am

Was it billed as a physical or as a new patient visit?

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JHU ALmuni
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Re: Medical Billing, is this typical?

Post by JHU ALmuni » Wed Jan 08, 2020 11:41 am

Mr. Rumples wrote:
Wed Jan 08, 2020 10:27 am
You can also file a complaint with the NY board of medicine if you don't get an adequate response. You may also request your medical records which should indicate why such tests were ordered in the first place. The cost is limited to $0.75 per page so its cheap. Don't know about NY, but in VA the law is very clear that a physician cannot withhold medical records until a medical bill is paid, but they may require prepayment for the records.

As mentioned above, pay attention to time limits and document everything, every call, every name.

https://lac.org/wp-content/uploads/2014 ... t_form.pdf
Thank you, that's very helpful.

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JHU ALmuni
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Re: Medical Billing, is this typical?

Post by JHU ALmuni » Wed Jan 08, 2020 11:43 am

sailaway wrote:
Wed Jan 08, 2020 11:40 am
Was it billed as a physical or as a new patient visit?

It seems like it was billed as new patient visit because I see a charge for office visit.

EnjoyIt
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Re: Medical Billing, is this typical?

Post by EnjoyIt » Wed Jan 08, 2020 11:48 am

JHU ALmuni wrote:
Wed Jan 08, 2020 9:59 am
I recently started a new job and got new insurance so I scheduled an appointment with a new doctor for my annual physical. I went to the clinic not complaining from anything and the doctor ordered blood test (as usual), EKG, chest xray, sonogram on my pelvic, legs, and neck before he even see me. I thought this is how the annual physical is performed in NY (recently moved from another state) and did not ask any questions if these tests are included in my annual physical benefits or I will pay for it out of pocket. :oops:

Today I got my EOB letter and basically I need to pay close to $700 for these tests. Again I was there only for my annual physical and not complaining from anything. Usually these visits cost me $0 to $20 (if the doctor adds anything to the blood test) but to see a $700 is something I wasn't expecting.

How should I handle this? I know I should asked more questions but I didn't. Nothing similar to this happened before and considering I wasn't complaining from anything I though this is how annual physical is done here for a 36 years old male.
As you described it, these tests do not make any sense at all. Maybe there is more to the story and you had some physical findings or findings on your history that require imaging.

As you described it I would be very upset with a physician who does unnecessary testing that I can only assume was done in his/her office and charged you for it.

Notice how I keep writing "as you described it." There can be details you are missing that would change the entire story making everything done very reasonable.

Since we are not to give medical advice on this forum (and I agree with that.) Maybe it is worthwhile going to the office and inquiring why these tests were done on a healthy 36 year old and why you were not informed of their costs before hand. You may very well have a case against this physician where the NY State medical board can assist you. I would without a doubt report this individual and allow them to investigate the situation so that they don't take advantage of more people.

njuser
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Re: Medical Billing, is this typical?

Post by njuser » Wed Jan 08, 2020 12:25 pm

JHU ALmuni wrote:
Wed Jan 08, 2020 11:38 am
njuser wrote:
Wed Jan 08, 2020 10:16 am
That is not typical.
Thank you for the information. The issue is mainly with the Dr. Office not the insurance company. I haven't met my deductible so this is why I need to pay out of pocket for these extra tests. In this case can I still file a complaint with state department of insurance?
I would contact the doctor's office first and talk to the office manager. Explain your problem (I booked my annual well check visit, why were these tests recommended?) and see what their position is. *From what you have said*, there is no reason for all the tests you had in preparation for an annual well check. (It actually sounds ridiculous.) Doctors are well aware of what a 'well check' consists of and in some cases they may be responsible for not adhering to those parameters. Don't be afraid to do this and don't be put off by crabby office workers. Make them answer your questions.

If they cannot help you, I would file a complaint with your state agency via email. State that you booked an annual physical/well check and doctor recommended these tests, which you did, assuming they were typical for your exam. If nothing else, it brings this doctor's practices to their attention.

If the state comes back that there is nothing they can do, I would then call the providers individually and explain your problem and ask if they would give a discount for a prompt payment.

Retired 2017
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Re: Medical Billing, is this typical?

Post by Retired 2017 » Wed Jan 08, 2020 4:32 pm

Of course we don't know all the details but..Some doctors can very deceptively come up with justification for about anything they do and any test they order. I used to work with a few of those kind. The employer loved them for generating such high charges. Many of their patients loved them too for being so "thorough". They were nothing but dishonest. Sounds like you were scammed to me. I think you got off lucky at $700.

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Re: Medical Billing, is this typical?

Post by BogleFanGal » Wed Jan 08, 2020 6:40 pm

While $700 is high and certainly a couple of these tests seem suspicious, I have yet to go for a single annual wellness myself and not end up billed for a few "non covered" blood tests. Most are insurance-negotiated amounts like $20, $30/test, totaling maybe $100 tops and testing for things the doc feels are important preventive. I trust her judgement, so I let it go. But it is a little annoying, as the list of covered things seems to be shrinking. Example: every year, she'd do an EKG that was always covered by Aetna HDHP, but last year GEHA HDHP denied it, stating they only cover the bare minimum tests that the ACA plan does, even though I'm 50+ and it seems prudent to do it.

Same with my husband - he goes to a different PCP and also ends up out of pocket on a few blood tests every year that his doc deems as basic preventive for 50+ male that GEHA won't cover.
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AAA
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Re: Medical Billing, is this typical?

Post by AAA » Wed Jan 08, 2020 8:46 pm

Were all of these tests done at the doctor's own clinic or using outside resources?

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Cubicle
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Re: Medical Billing, is this typical?

Post by Cubicle » Thu Jan 09, 2020 12:36 am

JHU ALmuni wrote:
Wed Jan 08, 2020 9:59 am
I went to the clinic not complaining from anything and the doctor ordered blood test (as usual), EKG, chest xray, sonogram on my pelvic, legs, and neck before he even see me.
This is what caught me the most. Doesn't seem right. I could potentially pass the ekg, maybe possibly perhaps the chest x-ray (its a stretch). But not the ultrasounds without symptoms.

Question: The EOB said your portion is ~$700. Did the insurance cover any portion of these tests?

And if they doctor's office knows they push the envelope on these tests, they may not even demand payment from you, hoping you never even opened your EOB. It doesn't make it right, but I'd wait on them to contact me. And if they did ask for payment, I'd not easily acquiesce...

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Re: Medical Billing, is this typical?

Post by sambb » Thu Jan 09, 2020 12:51 am

error sorry

quantAndHold
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Re: Medical Billing, is this typical?

Post by quantAndHold » Thu Jan 09, 2020 1:06 am

There is no way I would pay that bill without a fight. A healthy 36 year old doesn’t need any of those tests. I’ve never had some of them, and I’m quite a bit older.

On my annual wellness exam, the only thing I’ve ever been billed for was one blood test to monitor an existing condition. Of course, the doctor never tried to pull something like this on me.

I would also file a complaint with the state, regardless of whether or not they waive the charges. If they’re doing this to you, they’re doing it to others.

And find a new doctor.

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JHU ALmuni
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Re: Medical Billing, is this typical?

Post by JHU ALmuni » Thu Jan 09, 2020 7:21 am

AAA wrote:
Wed Jan 08, 2020 8:46 pm
Were all of these tests done at the doctor's own clinic or using outside resources?
Everything was done at the doctor's own clinic.

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JHU ALmuni
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Re: Medical Billing, is this typical?

Post by JHU ALmuni » Thu Jan 09, 2020 7:23 am

Cubicle wrote:
Thu Jan 09, 2020 12:36 am
JHU ALmuni wrote:
Wed Jan 08, 2020 9:59 am
I went to the clinic not complaining from anything and the doctor ordered blood test (as usual), EKG, chest xray, sonogram on my pelvic, legs, and neck before he even see me.
This is what caught me the most. Doesn't seem right. I could potentially pass the ekg, maybe possibly perhaps the chest x-ray (its a stretch). But not the ultrasounds without symptoms.

Question: The EOB said your portion is ~$700. Did the insurance cover any portion of these tests?
Not covered by the insurance because I haven't met my deductible yet, so everything is my responsibility.

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Re: Medical Billing, is this typical?

Post by RickBoglehead » Thu Jan 09, 2020 7:25 am

JHU ALmuni wrote:
Thu Jan 09, 2020 7:21 am
AAA wrote:
Wed Jan 08, 2020 8:46 pm
Were all of these tests done at the doctor's own clinic or using outside resources?
Everything was done at the doctor's own clinic.
Bingo.

Your annual exam should be free. You note you were charged for it. That's a problem.

Unless you sent records to the doctor ahead of time indicating issues, any of those tests ordered ahead of time, besides a basic blood test, are unwarranted. I can't tell you the last time I got an EKG. X-Ray only if they suspected pneumonia, and I've never had a sonogram in my life.
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Re: Medical Billing, is this typical?

Post by njuser » Thu Jan 09, 2020 7:49 am

JHU ALmuni wrote:
Thu Jan 09, 2020 7:21 am
AAA wrote:
Wed Jan 08, 2020 8:46 pm
Were all of these tests done at the doctor's own clinic or using outside resources?
Everything was done at the doctor's own clinic.
Then I would most definitely take it up with the doctor's office as he is the provider who is going to charge you. Again, he knows what is preventive care and what is not. You booked an annual checkup, not a diagnostic visit. I think it will be easier to fight this as they are the ones who will have to deal with a formal complaint, rather than multiple outside providers.

Many, many people get a medical bill and simply pay it; they do not want to spend the time, or simply don't have the time, or ability, to fight it. This is a case where squeaky wheel gets the oil and I would be persistent with them until they can resolve to your satisfaction.

I agree that extra blood tests are almost unavoidable at a well check. Any one that it 'not preventive' will generate the copay or coinsurance. I have tried to avoid it, to no avail. (I even got charged a copay even though I refused the test because the doctor wrote for the test on the order. Long story.) But all of these tests are really questionable if an annual well check was all that was expected.

ps get a new doctor.

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Re: Medical Billing, is this typical?

Post by RickBoglehead » Thu Jan 09, 2020 8:01 am

njuser wrote:
Thu Jan 09, 2020 7:49 am
JHU ALmuni wrote:
Thu Jan 09, 2020 7:21 am
AAA wrote:
Wed Jan 08, 2020 8:46 pm
Were all of these tests done at the doctor's own clinic or using outside resources?
Everything was done at the doctor's own clinic.
Then I would most definitely take it up with the doctor's office as he is the provider who is going to charge you. Again, he knows what is preventative care and what is not. You booked an annual checkup, not a diagnostic visit. I think it will be easier to fight this as they are the ones who will have to deal with a formal complaint, rather than outside providers.

Many, many people get a medical bill and simply pay it; they do not want to spend the time, or simply don't have the time, or ability, to fight it. This is a case where squeaky wheel gets the oil and I would be persistent with them until they can resolve to your satisfaction.
Actually, it's the insurance company that decides the coding of tests as preventative or diagnostic. We found out the hard way some years ago, when our Blue Cross PPO plan was removed from our choices, and we had to go with another PPO plan. At our annual physicals, the doctors (two different practices) routinely ordered a CBC (complete blood count), Metabolic Panel (metabolism, glucose), and Lipid panel (cholesterol). The new provider considers only the Lipid test preventative, and the others are always diagnostic.

Further, this provider only looks at the first diagnostic code provided, and if it's not Z00.00 (preventative), then it's not preventative. They ignore any other coding.

If I had the tests done that the OP did, you can see they'd be diagnostic and applied to the deductible.

As a result of our new health plan, we asked the doctors each time if the test is necessary given that the cost will be out of pocket, and we even tell them the cost (based on prior year), so they can make a proper judgement. This year I will be having a procedure that will eat up my deductible, so when I go for my physical I intend to tell the doctor to perform every diagnostic test that he deems necessary given that they will all be covered. It's like bunching up your contributions into one year to be able to itemize. :D
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Re: Medical Billing, is this typical?

Post by njuser » Thu Jan 09, 2020 8:26 am

RickBoglehead wrote:
Thu Jan 09, 2020 8:01 am
Actually, it's the insurance company that decides the coding of tests as preventative or diagnostic. We found out the hard way some years ago, when our Blue Cross PPO plan was removed from our choices, and we had to go with another PPO plan. At our annual physicals, the doctors (two different practices) routinely ordered a CBC (complete blood count), Metabolic Panel (metabolism, glucose), and Lipid panel (cholesterol). The new provider considers only the Lipid test preventative, and the others are always diagnostic.

Further, this provider only looks at the first diagnostic code provided, and if it's not Z00.00 (preventative), then it's not preventative. They ignore any other coding.

I am referring to this:
Under the Affordable Care Act, nearly all health plans have to provide certain preventive care to their members at no cost. You likely won't have to pay a copay, coinsurance, or even a deductible to get these exams when they're used to help find conditions or diseases early, before you have symptoms.

The doctors here are also required to refer you to an in network lab. If they don't, they are responsible for the cost. This happened to a family member. Referred to out of network lab. Received $1500 bill. Went back to office manager with complaint and referred to lab patient advocate. Bill was removed.

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Re: Medical Billing, is this typical?

Post by Jason622 » Thu Jan 09, 2020 8:48 am

It is certainly not ethical to order tests even before seeing a patient. I don’t know if it meets illegal standard. No test is justified without clear reason for it.

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Re: Medical Billing, is this typical?

Post by Jason622 » Thu Jan 09, 2020 8:49 am

Forgot to mention, please do not make him your regular primary care provider. He doesn’t seem worth.

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Re: Medical Billing, is this typical?

Post by BogleFanGal » Thu Jan 09, 2020 9:52 am

Cubicle wrote:
Thu Jan 09, 2020 12:36 am
JHU ALmuni wrote:
Wed Jan 08, 2020 9:59 am
sonogram on my pelvic, legs, and neck before he even see me.
agreed that this part is all highly suspicious - a new patient hasn't even seen the doc and he's ordering stuff like sonograms? I've seen my PCP for years and she still schedules the in-person checkup and discussion before ordering any tests or bloodwork.
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Re: Medical Billing, is this typical?

Post by LadyGeek » Thu Jan 09, 2020 5:49 pm

I removed an off-topic post suggesting when to have a physical exam or not (medical advice). As a reminder, see: Medical Issues
Questions on medical issues are beyond the scope of the forum. If you are looking for medical information online, I suggest you start with the Medical Library Association's User's Guide to Finding and Evaluating Health Information on the Web which, in addition to providing guidance on evaluating health information, includes a list of their top recommended sites.
Please stay focused on the billing aspects.
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Re: Medical Billing, is this typical?

Post by Trader Joe » Thu Jan 09, 2020 5:53 pm

JHU ALmuni wrote:
Wed Jan 08, 2020 9:59 am
I recently started a new job and got new insurance so I scheduled an appointment with a new doctor for my annual physical. I went to the clinic not complaining from anything and the doctor ordered blood test (as usual), EKG, chest xray, sonogram on my pelvic, legs, and neck before he even see me. I thought this is how the annual physical is performed in NY (recently moved from another state) and did not ask any questions if these tests are included in my annual physical benefits or I will pay for it out of pocket. :oops:

Today I got my EOB letter and basically I need to pay close to $700 for these tests. Again I was there only for my annual physical and not complaining from anything. Usually these visits cost me $0 to $20 (if the doctor adds anything to the blood test) but to see a $700 is something I wasn't expecting.

How should I handle this? I know I should asked more questions but I didn't. Nothing similar to this happened before and considering I wasn't complaining from anything I though this is how annual physical is done here for a 36 years old male.
This sounds atypical. I would dispute the charges and I would file a complaint.

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Re: Medical Billing, is this typical?

Post by Cubicle » Fri Jan 10, 2020 12:30 am

JHU ALmuni wrote:
Thu Jan 09, 2020 7:23 am
Cubicle wrote:
Thu Jan 09, 2020 12:36 am
This is what caught me the most. Doesn't seem right. I could potentially pass the ekg, maybe possibly perhaps the chest x-ray (its a stretch). But not the ultrasounds without symptoms.

Question: The EOB said your portion is ~$700. Did the insurance cover any portion of these tests?
Not covered by the insurance because I haven't met my deductible yet, so everything is my responsibility.
I should have phrased it better. Deductible understood. But, did your insurance "approve" any of these charges/tests? Because if yes, then hopefully you are getting a contracted (discounted) rate, & the provider shouldn't hold you to more than what the insurance states the provider would have been paid by the insurance. If they were not approved, then you may be able to use that against paying: "the insurance company didn't feel these charges were necessary, so why did you order them at all?".

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Re: Medical Billing, is this typical?

Post by unclescrooge » Fri Jan 10, 2020 1:59 am

njuser wrote:
Wed Jan 08, 2020 10:16 am
That is not typical.

Insurance is telling you what you are responsible for via the EOB; they are not judging whether a test is or is not appropriate. Look at each charge and see why it was charged. Here is a list of preventative services which should be included in your 'annual physical'. It is quite limited: https://www.healthcare.gov/preventive-care-adults/

When you are at your annual physical, if you do not want to pay for 'extra services', it is best to limit your questions. If you ask about any pains, symptoms, etc. it then becomes a diagnostic visit, for which your deductible/coinsurance will apply.

If it was me, I would go back and complain to the doctor's office. Tell them that you booked an annual physical, not a diagnostic visit. Ask them why they required all these tests for a well check. If they are not helpful, tell them that you are going to follow up with a formal complaint to your state's insurance department.

If they are not cooperative, your next move would be to write a letter of complaint to your state's insurance department. There is a 'file a complaint' button on this page https://www.dfs.ny.gov/consumers/health ... e_consumer

I would not pay these bills until you have contacted both the doctor's office and your state department of insurance. There is usually a time limit to file a complaint so be prompt. I have written my department of insurance in NJ and they answered fairly promptly (2 weeks) and were helpful.

Good luck. In the future, refer to your insurance company's summary of benefits before you get any tests done so you know what you would be covered for. Also question your doctor as to why you need each test. If you don't agree, seek a second opinion or refuse the test.

If none of this works, your last resort is to call each provider's billing department and try to negotiate a discount.
Do these preventive checkups include the cost of lab work under free screenings?

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Re: Medical Billing, is this typical?

Post by dodecahedron » Fri Jan 10, 2020 5:48 am

Your experience may not be typical but it is disturbingly common as this NPR Morning Edition article indicates.

NPR Morning Edition has a "bill of the month" series where they highlight an outrageous billing situation. I think yours would be a good candidate and you should consider submitting it. If NPR investigates and starts asking questions, I suspect your billing case and this questionable doctor might get the attention the situation deserves.

https://www.npr.org/sections/health-sho ... ll-with-us

Edited to add: even if insurance covers it, unnecessary medical tests costs all of us more money in higher premiums and taxes, so I would really encourage you to pursue all avenues for reporting this situation for further investigation.

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Re: Medical Billing, is this typical?

Post by njuser » Fri Jan 10, 2020 8:57 am

edit.
Last edited by njuser on Fri Jan 10, 2020 9:02 am, edited 1 time in total.

njuser
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Re: Medical Billing, is this typical?

Post by njuser » Fri Jan 10, 2020 8:58 am

njuser wrote:
Fri Jan 10, 2020 8:57 am
unclescrooge wrote:
Fri Jan 10, 2020 1:59 am
njuser wrote:
Wed Jan 08, 2020 10:16 am
That is not typical. ....

If none of this works, your last resort is to call each provider's billing department and try to negotiate a discount.
Do these preventive checkups include the cost of lab work under free screenings?
Preventive blood work is covered but if your doctor writes anything besides Z00.00 you will be charged for blood work.

After two recent experiences trying to get 'only' preventive care bloodwork I have come to the conclusion that it is very difficult thing to do. There is always something the doctor wants to screen for and chances are it will not fall under preventive care and I will have to pay a copay. A family member had blood work done, questioned a test at the lab facility, refused that particular test and was still billed a copay because the doctor wrote it on the order. Tried to rectify with insurance company, they gave me wrong info (long story), and I finally gave up and paid.

Here is a for ex: A woman has an annual wellness exam and receives
blood tests to screen for iron, kidney or liver function,
in addition to a urinalysis.
Answer: If the physician orders lab work during a
preventive care visit some of the tests may be covered
as preventive care, such as a cholesterol screening.
However, other blood chemistry panels like iron, kidney
or liver function and urinalysis, would not be covered
as preventive care. These are not considered services
covered without cost, under the preventive care
guidelines. The woman would be responsible for any
deductible, coinsurance, or copayment that may be
applicable based on her Benefit Plan provisions.

OP's situation is unusual because he was told to get several different tests that are not typical of an annual exam. We aren't just talking about bloodwork here.

J45
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Re: Medical Billing, is this typical?

Post by J45 » Fri Jan 10, 2020 9:43 am

Sorry about such a terrible (or may be excellent!) physical :D You should do the following:

Ask for all the records of your visit. Tell them, you need every page including doctor's orders!

Put in doctor's name here and check if there are any issues
https://apps.health.ny.gov/pubdoh/profe ... ome.action

A healthy 36yo if you have no medical history of anything serious, does not need imaging like X-ray, USG etc. Look into what indications, the doctor wrote while ordering all this workup. Typically, they have to justify every test when writing an order. It could be one word e.g. Physical exam. In case you have any medical issues, then all this may be justified in terms of complications. Also, they should have told you beforehand, that you will be paying out of pocket.

Then complain to OPMC
https://www.health.ny.gov/professionals ... plaint.htm

There are good doctors and then there are crooks who need to be stopped. Feel free to pm me if you have more questions.

Topic Author
JHU ALmuni
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Re: Medical Billing, is this typical?

Post by JHU ALmuni » Fri Jan 10, 2020 8:53 pm

Well, things got even more interesting. I just got a bill from the lab for blood tests and the total is $2,900 :annoyed :annoyed

RJC
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Re: Medical Billing, is this typical?

Post by RJC » Fri Jan 10, 2020 9:14 pm

JHU ALmuni wrote:
Fri Jan 10, 2020 8:53 pm
Well, things got even more interesting. I just got a bill from the lab for blood tests and the total is $2,900 :annoyed :annoyed
Perhaps they billed you for diagnostic labs vs preventative labs?

Big Worm
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Re: Medical Billing, is this typical?

Post by Big Worm » Fri Jan 10, 2020 9:32 pm

None of this stuff was even remotely necessary, except maybe the bloodwork.

The quickest way to get the docs attention is let him know you are filing a complaint with the state medical board.

I don't know how NY is but in my state an investigator will crawl where the sun doesn't shine very quickly.

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Cubicle
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Re: Medical Billing, is this typical?

Post by Cubicle » Sat Jan 11, 2020 2:27 am

JHU ALmuni wrote:
Fri Jan 10, 2020 8:53 pm
Well, things got even more interesting. I just got a bill from the lab for blood tests and the total is $2,900 :annoyed :annoyed
Interesting indeed...

What is the difference between the $700 EOB & this new bill? The reasoning I mean... Not covered? Deductible? Out of network?

Brings this recent story back to my mind:

https://www.kvpr.org/post/her-head-cold ... ghed-25865

toofache32
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Re: Medical Billing, is this typical?

Post by toofache32 » Sat Jan 11, 2020 7:38 pm

Cubicle wrote:
Sat Jan 11, 2020 2:27 am
JHU ALmuni wrote:
Fri Jan 10, 2020 8:53 pm
Well, things got even more interesting. I just got a bill from the lab for blood tests and the total is $2,900 :annoyed :annoyed
Interesting indeed...

What is the difference between the $700 EOB & this new bill? The reasoning I mean... Not covered? Deductible? Out of network?

Brings this recent story back to my mind:

https://www.kvpr.org/post/her-head-cold ... ghed-25865
This is from the lab, not the doctor.

StrangePenguin
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Re: Medical Billing, is this typical?

Post by StrangePenguin » Sat Jan 11, 2020 11:56 pm

JHU ALmuni wrote:
Fri Jan 10, 2020 8:53 pm
Well, things got even more interesting. I just got a bill from the lab for blood tests and the total is $2,900 :annoyed :annoyed
As everyone else said, this whole thing sounds very shady.

As you analyze the situation (and tell us about it), keep all of the details straight.

Each test billed by the doctor or lab should be submitted to insurance. Even if you haven't met your deductible yet, the insurance will approve or deny the claim and classify it as in-network or out-of-network. For each procedure/test you should get both an EOB from the insurance company AND separately a bill. For a standard in-network charge, the EOB should tell you the amount the provider billed, the discount you get because of the negotiated rate between the provider and the insurance, the amount the insurance paid (might be 0 until you hit the deductible), and finally the amount you owe. Try to line up those "amount you owe" from the EOBs with the actual bills from providers.

You want to keep an eye out for:
* provider/lab is billing you without submitting an insurance claim
* provider/lab's claim was denied by insurance
* provider/lab is not in-network

(Of course just because the billing is correct for what are probably unnecessary tests doesn't make everything ok.)

michaelingp
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Re: Medical Billing, is this typical?

Post by michaelingp » Sun Jan 12, 2020 6:23 pm

There is a lot that's disturbing here, but I'm confused about the EOB. Since there was an EOB, the doctor's office must have submitted the charges to your insurance company. All I can think is that your new insurance requires you to use what most here are calling "in network". Some insurance companies say "preferred providers" or similar. If your insurance requires you to go to in network doctors, and your doctor is not in network, then the insurance company has no contract with the doctor and they can basically charge you whatever they want. Even with your deductible, if the insurance company had a contract with the doctor, then the EOB would show both the charge the doctor submitted, and the negotiated charge the insurance company would allow, and you should only pay the negotiated amount. In my experience with insurance and Medicare, I don't care how many useless tests they gave you, it would never add up to $700 or $2,900. Also, if the doctor is not in network, they should have informed you of that in the very first place.

For reference, for example, if my doctor orders an EKG (I'm 68), they give me a form to sign saying my insurance might not pay for it (they always do) and if they don't I'm on the hook for a grand total of $80 or something.

sawhorse
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Re: Medical Billing, is this typical?

Post by sawhorse » Mon Jan 13, 2020 8:24 am

dodecahedron wrote:
Fri Jan 10, 2020 5:48 am
Your experience may not be typical but it is disturbingly common as this NPR Morning Edition article indicates.

NPR Morning Edition has a "bill of the month" series where they highlight an outrageous billing situation. I think yours would be a good candidate and you should consider submitting it. If NPR investigates and starts asking questions, I suspect your billing case and this questionable doctor might get the attention the situation deserves.

https://www.npr.org/sections/health-sho ... ll-with-us

Edited to add: even if insurance covers it, unnecessary medical tests costs all of us more money in higher premiums and taxes, so I would really encourage you to pursue all avenues for reporting this situation for further investigation.
I can't second this post enough. If the situation is exactly as you described, then we need people to speak up to the media and authorities. Nothing will change otherwise.

EnjoyTheJourney
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Re: Medical Billing, is this typical?

Post by EnjoyTheJourney » Mon Jan 13, 2020 9:38 am

I've learned to ask questions both before services are performed and after any surprise bill is received.

One recent case in point ...

We received a surprise bill of about $2,500 recently for a test which I had phoned ahead of time to confirm was covered and didn't require preapproval (never leave out that step for tests, in my experience, regardless of what the doctor's office says). After phoning my insurance company to inquire about what happened it came to light that the lab hadn't submitted a claim, but instead had sought to directly bill us. Further inquiry led to learning that the lab didn't have our insurance information.

It was a staff member in the doctor's office that had made an error, in the end. That time. But, any number of reasons are possible.

More generally, it's a lot simpler for the doctor's office (and probably more profitable) to work with patients who do what they're told when it's most convenient for the doctor's office. So, even though there's a degree of empathy and understanding for patients who are nervous about getting bushwhacked by surprise bills, in my experience there are mixed levels of support for giving patients time and space to work those issues out unless the patient requests it*. Also, providers pay a very small sum to send out a large bill to a patient and doing so probably more than pays for itself, so they keep doing it and often don't bother to inquire about insurance when the information is missing.

Essentially, you need to be willing to be a bit of sandpaper in the system, even when those with whom you're dealing would prefer that you just do what they're telling you to do.

* I've had doctors take the time to ensure our insurance would work out and I put quite a bit more trust in such doctors; my sense is that they're probably also more caring about their patients in general and more careful in their medical work, or perhaps that's just my bias. When a doctor seems indifferent about billing issues then to me that's a red flag and I'll probably refuse the services being offered and not see that doctor again.

michaeljc70
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Re: Medical Billing, is this typical?

Post by michaeljc70 » Mon Jan 13, 2020 10:03 am

Get a new doctor. As described this sounds like a scheme to increase revenue.

I've never had a chest xray or EKG or sonogram in my whole life and I get a physical every year.

I would definitely question the doctor's office as to why all this was done.

Shallowpockets
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Re: Medical Billing, is this typical?

Post by Shallowpockets » Mon Jan 13, 2020 10:11 am

Retired 2017 wrote:
Wed Jan 08, 2020 4:32 pm
Of course we don't know all the details but..Some doctors can very deceptively come up with justification for about anything they do and any test they order. I used to work with a few of those kind. The employer loved them for generating such high charges. Many of their patients loved them too for being so "thorough". They were nothing but dishonest. Sounds like you were scammed to me. I think you got off lucky at $700.

This is your truth. there is no Medicare backstop on young private insure patient. No justification needed for tests.
This is a lesson to ask questions next times.

njuser
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Re: Medical Billing, is this typical?

Post by njuser » Tue Jan 14, 2020 11:19 am

JHU ALmuni wrote:
Fri Jan 10, 2020 8:53 pm
Well, things got even more interesting. I just got a bill from the lab for blood tests and the total is $2,900 :annoyed :annoyed
I hope that you have been in contact with the doctor's office. That kind of bill makes me think that you did not use an in network provider for your blood work. Where did they take the blood sample? In any case, it still may be contested. Look at your EOB to see why it was billed to you. Go from there.

If the doctor's office is not helpful, call the lab that did the bloodwork. When I had a similar problem, the doctor's office didn't want to take responsibility, but they did put me in touch with the lab's patient representative, who waived the bill ($1500).

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unclescrooge
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Re: Medical Billing, is this typical?

Post by unclescrooge » Tue Jan 14, 2020 11:25 am

Cubicle wrote:
Sat Jan 11, 2020 2:27 am
JHU ALmuni wrote:
Fri Jan 10, 2020 8:53 pm
Well, things got even more interesting. I just got a bill from the lab for blood tests and the total is $2,900 :annoyed :annoyed
Interesting indeed...

What is the difference between the $700 EOB & this new bill? The reasoning I mean... Not covered? Deductible? Out of network?

Brings this recent story back to my mind:

https://www.kvpr.org/post/her-head-cold ... ghed-25865
:shock:
Holy mackerel!

Topic Author
JHU ALmuni
Posts: 139
Joined: Tue Jan 20, 2015 12:40 pm

Re: Medical Billing, is this typical?

Post by JHU ALmuni » Thu Jan 16, 2020 12:09 pm

Update:

Talked the the Dr. Office and the office manager told me to come to the office and they will help me. Went in this morning and they took off all of the charges that was billed at their office and made a copy of the lab bill and said they should be able to resubmit it to the lab as annual physical to remove the charges but will confirm with the Dr and get back to me. :shock:

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anon_investor
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Re: Medical Billing, is this typical?

Post by anon_investor » Thu Jan 16, 2020 12:12 pm

JHU ALmuni wrote:
Thu Jan 16, 2020 12:09 pm
Update:

Talked the the Dr. Office and the office manager told me to come to the office and they will help me. Went in this morning and they took off all of the charges that was billed at their office and made a copy of the lab bill and said they should be able to resubmit it to the lab as annual physical to remove the charges but will confirm with the Dr and get back to me. :shock:
Hope this works out for you. I had something like this happened before, its all about how they submit the request to insurance...

njuser
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Re: Medical Billing, is this typical?

Post by njuser » Fri Jan 17, 2020 6:30 pm

JHU ALmuni wrote:
Thu Jan 16, 2020 12:09 pm
Update:

Talked the the Dr. Office and the office manager told me to come to the office and they will help me. Went in this morning and they took off all of the charges that was billed at their office and made a copy of the lab bill and said they should be able to resubmit it to the lab as annual physical to remove the charges but will confirm with the Dr and get back to me. :shock:
I wonder what they do with people who just pay and don't ask any questions.

jk, I don't really wonder.

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