Biopsy Cost / Lab Out Of Network Surprise Bill

I just had a prostate biopsy done. I spoke at length with the facility and my insurance company beforehand to get an idea of the costs involved. The approximate cost for biopsy was supposed to be somewhere in the neighborhood of $250-$450. I don't recall what the lab cost was going to be, but through my insurance it's usually very reasonable... blood tests are $25 flat fee, for example.

I received my "bill" in the mail today for the biopsy: $456

I also received a "bill" for lab work that my insurance company claims is out-of-network and the bill was $6000. Yes, you read that right 6 THOUSAND dollars. My "negotiated" rate is $4500, although on the statement it says the provider will likely want more than that.

Has anyone else had this kind of issue? How much should that lab cost be? I was under the impression it would be in the range of $50 - $100.

Please help if anyone has any ideas or suggestions.

I meet with my uro on Wed to get my lab results. They only present those results in-person, so there'll be another office visit...

Thanks,

Paul

Was the $6.5K just to read the slides? Bostwick, et. al. only charges something in the $250 range. I suppose they are attempting to punish you for going out of network. They probably have an appeal process you can use. Gather data and file your appeal.

Look into hiring a good attorney, one who specializes in this area. It may cost you some, but it may just turn out to be money well spent.

Often when the other side learns that you have a good attorney working for you, they suddenly become much more agreeable to negotiation.

Hubby's biopsy was done at the radiologist office who is in-network. They chose to send some of the lab work to places out-of-network. The charges were listed on my EOB from the BCBS but I was never charged for any of those. Only the co-pays from the radiologist office (plus the applicable deductable for our plan).

I have noticed that while 100% of hubby's Lupron injection was covered at the Urologist's office, we had to pay 10% co-pay when he gets the injection from the oncology office. Maybe because it's considered Out Patient services? We like the oncologist and not the urologist so we've put up with the extra costs.

I really need to call the insurance company about that. . .

You must be almost vicious about checking pre-authorizations these days. Be sure that everything has a preauth, get it in writing, and understand if it is in-network or not. Even the ER can get you. Call the number on you insurance card and get confimation details for everything. And remember, a hospital or clinic may be in-network, but some of the doctors may not be.

For reference,

- in-network is a provider who agrees to take the insurance plan's payment as full payment if the service is covered by your policy. You may have a separate in-network deductible or co-pay to meet before the insurance pays.

- out-of-network is a provider who does not participate. Your insurance MAY pay something, usually a percentage of what they consider "reasonable & customary", but you have to make up the difference.

- out-of-network, but accepts network pricing (this is where my GP and Uro fall). They are not participating, but they accept the "agreed price" as what they will charge, and they respect my in-network deductible and out of pocket limits.

I spend as much time fighting the insurance battles as I spend fighting PCa.

Paul TT, just to clarify, if the 'negotiated rate' is $4500, does that mean that is the amount that your insurance carrier will reimburse to you for having these tests done? If that's the case, doesn't that mean that, although the charges are ridiculous, you'd have to put up the difference between that $4500 and the bill's $6000 ($1500)? Sorry if I'm wrong, that's just how it works with mine. As far as lab costs, I've had lab work billed for a few hundred dollars, and my insurance negotiated rate was about $15--and that's what they were paid-$15!

Insurance is surely a mess of twisted logic. If I use someone 'out of network' my insurance, Carefirst BC/BS will still reimburse me the same rate that they would to an in-network provider, less a 20% coinsurance 'penalty.' I have to pay that difference between the payment and the bill, however. Thankfully I also have a yearly 'out of pocket' maximum that's not too unreasonable, and then they'll pay 100% through the end of that 'insurance year.' In fact, after I had my first set appointment with my surgeon, I found out the day of my initial consult, while checking in, that he didn't accept my insurance. I thought "Are you kidding me? Who does _not_ accept _this_??!!" He agreed to see me as it wasn't my fault (I gave my insurance info at appointment scheduling without a peep) and the appointment went well, but I still ended up hitting that 'out of pocket' max for the first and, so far, only time! Thankfully the hospital services weren't an issue and were covered @ 100%.

On the other hand, I had a coworker a few years ago that had a horse riding accident and was transported via ambulance to the local ER. After all was said and done, all the hospital bills were paid---except for the ER doc. He wasn't a participating provider! How in the world do these things happen? Are we expected to make a phone call to the hospital prior to our ambulance arriving and order only a participating doctor attend us--while we are unconscious?!?!

Usually if the out network provider accepts the insurance company rate, that's what you will pay. Your plan will dictate what the co-pay of the 4500 you are responsible for.

My insurance normally is 20% co pay in network and 40% out of network, once deductible is met, that's how you can go bankrupt while being insured.

If docs submitted wrong codes they can re-submit them.

The system is working as designed, to extract maximum profit

Sometimes when charges mysteriously go away it's because of the wrong code issue (which the docs office may have resubmitted without telling you). Not necessarily fraud.

If you have to be in the club, that's an excellent entry point.

Apart from the network confusion and need for pre-authorization, a big issue is coding. I think the initial code was wrong. Though it was a few years ago, my total cost for the biopsy including Bostwick pathology and related readings was about $1,200.

Another big issue with the costs is that so many clinical practices have merged with, been purchased by, or become associated with a hospital. The hospital then does the billing and can add all the "associated services" charges to the bill. This includes the pharmacy, cafeteria, operating rooms, morgue, emergency room, etc. Though you didn't use any of them, you get charged for them. This, in my opinion, has significantly increased the cost of healthcare as about 40% of the doctors and clinics have been scooped up by the hospitals in the last 10-15 years for this very reason.

Fairwind said...
"On the other hand, I had a coworker a few years ago that had a horse riding accident and was transported via ambulance to the local ER. After all was said and done, all the hospital bills were paid---except for the ER doc. He wasn't a participating provider! How in the world do these things happen? Are we expected to make a phone call to the hospital prior to our ambulance arriving and order only a participating doctor attend us--while we are unconscious?!?!"

Maybe I can explain that....Hospitals today are for profit corporations..Their ER's are minimally staffed by doctors and nurses who are hospital employees, you will get no separate bill from them..But on weekends or when they are busy or you need a specialist they do not employ, they call outside doctors to come in and work as contractors (say an orthopedic surgeon) and THESE doctors and specialists may not be in your network and will bill you directly. If they can, a GOOD hospital's ER will try to match your insurance to an on-call doctor who is "in network" to your insurance policy..

In my area, the emergency units of the two hospitals that I have become acquainted with are staffed by a separate group of emergency physicians, not hospital staff. This group may, or may not, be part of your insurance plan. I do agree that it is unfair to have this situation.

Single payer system would solve all of this and bring the cost of healthcare down tremendously.

searchinginla....and our taxes would jump according. But let's not make this make this into a political discussion.

I _do_ however think the subject would be an interesting 'sticky' thread to compare how the various systems work.

MD