The $800 Preventive Lab Work Bill

I cannot overstate the importance of carefully reading your medical bills and comparing them to your Explanation of Benefits document from your insurance. 

In September, I visited my primary care doctor at Froedtert for an annual physical, which is supposed to be covered at 100% by all full insurance plans. She ran some regular lab work typical with any physical. I was pretty shocked to then get a $800 bill for the lab work portion of my visit. 

I contacted my insurance company right away, because I know my insurance plan inside and out (of course!) and know something went seriously wrong. Turns out, from their end, some of the labs that were sent in are not considered as part of the preventive work by Allstate (my insurer) because of their different interpretation of the Affordable Care Act mandates. 

Now, this is not particularly unique. Two weeks ago, I helped a client with the same issue with United Health Care. A month before that, Molina. All ACA-compliant carriers. This is, in a word, typical. And almost always a struggle. Insurance blames the hospital system, the hospital system blames insurance. In my experience, the blame is equally divided. 

So, what can be done? First, DO NOT WAIT. Insurance always has time limitations on when appeals can be filed, and when they will look at claims. Hospitals typically wait only 90 days before they start nudging toward collections.  You need to take action right away. 

The first thing you should do is get a written appeal in to your insurance company within their appeal timelines. Write a short letter that contains your full contact information, your ID number, and information about the claim like the date of the service, amount charged, name of doctor. Keep a copy of that appeal and a note about when you mailed it. 

The second thing you can do is contact your doctor about properly coding the claims. Most hospital systems have outsourced insurance billing, so there is a disconnect between your doctor who ordered the service and the person who typed it up and sent it in to insurance. This can lead to wrong codes being used and services being denied. Contact your doctor directly for help. They can often request internally that billing use a better code. 

If you lose your appeal with insurance, follow your next step appeal rights. You can request a reconsideration, or some kinds of insurance even allow for an outside oversight organization (sometimes called an Ombudsman) to review the appeal. 

If that still doesn't work, you can file a complaint with your state department of insurance. In Wisconsin, that's the Office of the Commissioner of Insurance. 

If insurance says that your hospital is simply refusing to bill the right code, or they are still trying to collect, you can try filing a complaint against them with your state's Department of Consumer Protection. 

Generally speaking, as long as you take action quickly you won't yet be at the collections stage. It's critical to take swift action, because once you're in the collections stage it can be hard to impossible to resolve the issue, even if you're right. Please consider connecting with your state lawmakers to encourage them to pass real protections for consumers when it comes to medical billing practices. 

​