Insurance company issues... Need some advice please @_@!

iwakuralain16 · Post by **iwakuralain16** » Thu Sep 18, 2008 11:43 pm

So.. I was hoping to get some advice from fellow beta members about an issue I ran into recently. Was wondering if anyone has been through anything similar.. and what the results were. This is long.. sorry. @_@

I am currently insured by United Healthcare(PPO) through my employer. To say the least, my employer rocks and their benefits are freakin awesome! So two friends and myself have decided to “get healthy” and see who can get fit the fastest. Lose weight… work out… etc. My friend is going to the military so he actually has to lose some weight before they will let him in. ANYWAYS.

Last month I went to the doctor that was recommended by my guy friend. We all have the same insurance so I double checked to make sure this guy was a network doctor. He was, so I set up an appointment. I went in for the check up and they recommended I get a test done to make sure nothing is wrong with my thyroid. He said I didn’t have to, but I thought “What the hell, why not?”. Plus I wanted them to check for diabetes because it runs in my family like the freakin plague. LOL So he said it is covered within the visit, no prob. I paid my $20 and I left.
Last week.. I get a explanation of benefits from my insurance company rambling on about how I went to an out of network provider and they only covered a portion of it. I thought… wait a minute.. the doc was in network.. what the hell. I look at the company… Quest Diagnostics… Lab Lab Lab… over and over again. So.. my lab stuff… okay… but I went to an in network doctor and the tests were done as an office visit. Why am I getting this? In fact online, it even shows Lab in my office visit...(the quest diagnostics bs is also shown as a completely seperate transaction). I ask my guy friend to see if he got anything like this because he also had the tests… nothing. My girl friend? YES. She threw away the letter but logged online to find out that the same thing happened to her. So I am furious. I waited until today to call and checked online before calling just in case… and another bill was processed from them. So now it is totally up to $500..

I call the insurance company and they said that the DR was in network.. but the lab service they used was not. I asked “And how was I supposed to know this? When it says office visits were covered including tests and preventive care and all of that?” He said it was processed correctly and it was the doctor that chose to send the tests there. So I asked about the appeals process and he said he could give the address but it will come back saying that it was processed correctly so there would be no change… so… I said okay. What are out next steps. He didn’t say anything… lol and finally said I could contact the Dr. So I said okay… and disconnected after thanking him.

So… I am going to call my doctor tomorrow. My dad had a similar issue before in the past with a doctor he visited and they just put on his chart to not use that lab… I had another friend at work say that once she went to a ER because regular doctors were not open and she chose a hospital that was in network but a out of network doctor helped her.. and her insurance tried to bill her $80 for it. She fought it for a month and they decided to go ahead and make an exception that one time and not make her pay. Well.. that was a hospital situation.. this is just a regular ol dr’s visit.

Has anyone else ever run into this before?!?! How are patients supposed to know about this type of stuff if they follow the rules? Choose a in network doctor and pay the co-pay and then get slapped in the face later because you did the right thing?? What the hell? What did you do.. if this happened to you…? O_O

I am a very patient person. I understand what these phone reps go through on a daily basis. I have NEVER lashed out at one… I usually just let things be…whatever. Working customer service sucks and it takes ALOT to get me pissed off. My plan is … I will call the insurance company.. every day. And escalate. I swear I will escalate and not let this go until they do something about it. I have 180 days to fix this before my time allowed to resolve this expires according to the EoB form I got. I will make at LEAST 180 calls to these people… LOL

Sorry.. ranting. Tell me what you think.

*EDIT*
I just did some research and it sounds like Quest Diagnostics used to be the main people who did the UCH labs but they chose labcorp to be the primary in network lab people. They also sent out letters to all preferred doctors/in network doctors saying that they must send the lab work to labcorp unless the patient states otherwise if a patient as thier insurance.. or they could have thier "preferred doctor" status taken away. I dunno.. still reading. Still extremely pissed but kinda hopeful. LOL

Post by **Kaona** » Fri Sep 19, 2008 12:34 am

Relax, stay calm and give your doctor's office a call in the morning. Don't leave a message for the doctor, but do ask for the biller or billing department. They will be able to find out what happened.

If the doctor's office sent the lab work to the one lab in the world United Healthcare does not cover, then the doctor's office would probably take the financial hit.

However, if the lab work was considered optional or needed pre-authorization, then you might enter a gray area. But, let's worry about that after we find out why they sent the lab work to the wrong/out of network lab.

Good luck and let us know!

cutiebunny · Post by **cutiebunny** » Fri Sep 19, 2008 12:38 am

Was there any explaination in a booklet you received prior to or after joinning the service explaining the costs for services?

I've dealt with things like this for years. My HMO for both healthcare and dental send me booklets ever so often explaining the costs per procedure and the amount I'll have to pay, per transaction, for this service. Basically, they break down every procedure into a cost that you'll pay, providing, of course, that you use a doctor in their network.

If you have this booklet around, does it say anything about lab work and how much the fees, if any, are? If there is nothing about this in the paperwork that you've received, then, you probably have a case for a small claims court. If there was something about it, or you don't have that booklet, it may be difficult to prove that you were unaware of these costs.

I agree with you that it is unfair that you have to pay for a service that was provided by a covered doctor, simply because the doctor chose to use a lab service that was not certified by the PPO.

Ultimately, I think you may get your money back as long as you're persistent with it. Most big companies don't like bad press, so, if worst comes to worst, you always have that as a trump card. The damage that you could do in an editorial in a local paper or a site like yelp could financially hurt the company more than the payment that you owe. I had a problem with AOL before and after riding them for a good three months, they refunded my money.

iwakuralain16 · Post by **iwakuralain16** » Fri Sep 19, 2008 1:08 am

cutiebunny wrote:Was there any explaination in a booklet you received prior to or after joinning the service explaining the costs for services?

I am sure I received stuff around enrollment time.. I just let them carry over the same PPO non high deductible plan I had last year. THey sent me a booklet about the different plans the company offered.. HMO or PPO and etc. Other than that, I really did not get anything else to my knowledge. I did look up a benefits booklet on the website and it did talk about lab costs and to make sure your doctor uses a in network lab. I rarely go to the doctor.. in fact... I never go because I have this over whelming fear that something like this could/would happen. The fact that this doctor told me it would be covered in the visit pisses me off. I gave them my info when I filled out paperwork to call the insurance to verify my coverage. Like I said when I edited my post above, Quest used to be the main people UHC used for labs until they changed it a couple of years ago. Maybe this doctor just forgot? I wish I had never went... so much for preventative care and taking the initiative to see a doc before I get sick. I usually never go unless I am really sick... and it is usually to one of those "Care Now" places.. who BTW did labs for me earlier this for other stuff and I had 0 problems. LOL

cutiebunny · Post by **cutiebunny** » Fri Sep 19, 2008 2:04 am

Assuming that what is printed online is what you received in your informational pamphlet prior to signing with the PPO, then, it sounds like you really don't have a case.

And the doctor can feign that he never said that the lab work was covered, so, unless you have it in writing, the 'he said/she said' game doesn't really cut it.

I know that's not the news you really wanted to hear, but, you can always try your luck with calling them and, if that doesn't work, bad press.

But, regardless of what you paid, at least you got a clean bill of health. There's a lot of people in this world who would pay $500 for that.

kathpatty · Post by **kathpatty** » Fri Sep 19, 2008 5:30 am

Koana is right.....

Relax, stay calm and give your doctor's office a call in the morning. Don't leave a message for the doctor, but do ask for the biller or billing department. They will be able to find out what happened. Wink

If the doctor's office sent the lab work to the one lab in the world United Healthcare does not cover, then the doctor's office would probably take the financial hit. D'oh

However, if the lab work was considered optional or needed pre-authorization, then you might enter a gray area.

Beware when you give your permission for testing... that usually means you are accepting the cost as providers are under strict guidelines by insurance companies as to what they may or may not order for you...

Gotta love insurance companies..

Best of luck

iwakuralain16 · Post by **iwakuralain16** » Fri Sep 19, 2008 9:21 am

I called the dr's office and had to leave a voice mail...

I called UHC again and spoke with a woman who reviewd my claim with me. She said that the amount I owe out of pocket is now $340ish dollars.. I do not remember the exact amount. I told her I don’t care if it is $300 or $500, this needs to be reviewed and solved. The lady I had on the line yelled at me saying that I owe the amount I owe because I used someone out of network, I told them that I had no control over that and the DR said it would be covered thus why I got the test. She shut up when I told her I did research online last night that as on January 1st of 2007, that United Healthcare made all of its in network preferred doctors aware that they will no longer have Quest as a preferred lab provider and that doctors can and will be fined by UHC if they use them as a default lab OR recommend them… unless the customer specifically requests to use Quest. Doctors were upset about this because a lot of labs are done outside of the Dr’s office and they can not control where the patient goes. This doctor had my blood taken in house, I know many other employees that work for the company I work for, go to this doctor. It is not too far from where I work and the receptionist at the front desk said they had a lot of people from my job go there. She said this after I told her I was recommended by someone from work. I told them that action needs to be taken because I am sure I will NOT be the only person who they will be hearing from about this. I also told her that I will call about this every day until I get a resolution to this problem so she may end up hearing from me again.

She regained her cool and told me she would send me to a research resolution specialist to research this item. I got a guy on the line was nice. He asked if I had spoken with the DR, I told him I have a left message but they have not contacted me back yet. He said the information I was seeing online was “out dated” and that they did cover a lot but I owe the $340. I repeated everything I said in the above paragraph and told him that this Dr was a “preferred cost efficient” doctor that was obviously made aware of this insurance plan change. Not just a plan change, this is for ANY plan with UHC. So to say he didn’t know, is nonsense! Maybe he forgot? Maybe it was a clerical error? I should NOT be punished for that. He said the most he could do and the most my insurance is willing to pay is 90% of the out of pocket amount. So that means and he clearly stated, I will pay 10% of the $340ish I owe. It will take them about 48 hours to review this and I should receive something in the mail in the next 10 business days an updated EOB and a letter. I told him I would be in contact and will be expecting something in the mail. When that mailing arrives, we will go from there. I thanked him for his time.. and disconnected.

We will see...

glorff · Post by **glorff** » Fri Sep 19, 2008 9:43 am

Have you talked to the human resources person in your office that handles insurance for the company? They are often able to accomplish things that you cannot.

If that does not help then you should find out who sold the plan to your company and get the agent to help.