Medical Insurance Adventure

In addition to the massive hospital bill after my bout with pneumonia I got, of course, a host of smaller bills from doctors, imaging centers, and laboratories which were peripheral to the process. UnitedHealthCare paid them as expected except that they denied payment on all of the bills from one particular lab which was billing for blood tests, citing a code which explained that “This code, when accompanied by a facility place of service, is not eligible for reimbursement to the physician."

Now, I know that various medical professions each have their own language, but that is not “doctor speak,” or “hospital speak,” or even “insurance speak.” That is just plain gibberish. No one bill was all that large, they ranged from $12.50 up to $135.00, but they totaled close to a thousand bucks, and I’m not coughing up that kind of money without a better explanation than that.

There was one bill, though, for $835.00 which the insurance paid, and that seemed very weird. It will make perfect sense when we finish this little adventure, but it seemed strange at the time.

I called the hospital and verified that they do, in fact, subcontract lab work to that company, and then I contacted the insurance company via a messaging system to ask why they were denying these claims and for a better explanation of the “service in a facility setting” denial.

They replied, “when you are in a hospital, the professional component for reading your lab tests is already incorporated in the hospital fees. In essence, if we pay this charge we would be paying the services twice.”

Okay, the explanation is no longer gibberish, but is now entirely bogus. My doctor might need the services of a radiologist to read an x-ray or a CT scan, but he certainly doesn’t need any help reading a damned blood test. Hell, even I can read a blood test. I might not know what the values mean, but my doctor certainly does.

So, I make an assumption and send another message to the effect that I don’t believe that they are billing for reading tests, but are billing for performing tests which are subcontracted to them by the hospital.

I receive a reply that the lab “is not billing for performing these tests they are billing for the professional component which is the reading of the tests,” and that the bill for performing the tests was submitted by the lab directly to the hospital.

So I call the laboratory and ask what they are billing for, and am told that they don’t read lab reports, all they do is generate them by performing the tests. The very nice person there informed me that they are an “out of network” provider to the insurance company and are therefor not bound by the stipulation prohibiting billing the patient for the difference between full price and the amount paid by insurance. The amount which they were billing direct to insurance is the discount which the hospital extends to the insurance company and which, not being paid by insurance, the hospital does not pay to the lab.

She went on to say that if I would appeal the denial based on the fact that I was a patient at an “in network” facility and had no choice on the performance of the lab work, that the insurance company would pay the claim. She added that she was marking my account to the effect that I was appealing and that they would wait for payment from insurance, thanked me for calling and wished me a nice day.

I then sent another message to the insurance company saying that I wanted to appeal the denials of payment based as the person at the lab had coached me, and received a prompt reply that an appeal was not necessary and that the responder would see to it that the claims were submitted for an “exception” and that payment would be made to the provider. She thanked me for using their messaging system and apologized for the inconvenience that I had incurred on the matter in question. Indeed.

I then went back and looked at the earlier messages and realized that the insurance company was never really taking a very firm stance in denying the claim. In the very first message, after saying that their policy was “not to pay this charge in a facility setting,” there was a statement toward the end that added, “If you are to be billed for this service we will be able to go back and take a second look at the claim for processing at the in network rate” which I had overlooked.

In the second message, after telling me that the lab was billing for reading the lab results and that “In essence, if we pay this charge we would be paying the services twice,” there was a similar admonition that, “Please send me a follow up message if you have received a bill from this provider. I will then be able to have your claims sent back to our transactions team for an exception to be made and benefits allowed for these charges,” which I had also missed because my attention was so focused on the novelty of the claim about the need for a specialist to read a blood test and the insanity about paying for services twice.

It was also a bit weird for her to be wanting to be told if I had received a bill from the provider, since they themselves had received the bill from the provider and sent an “explanation of benefit” to me and to the provider saying that I was expected to pay the bill. So what did they expect the provider to do if not send me a bill?

Now, I will admit that I am engaging in some mind reading here, which is not normally my strong suit. Ask my wife about that. But the evidence strongly supports my conclusion that UnitedHealthCare is filled to the brim with a substance which comes out of the South end of a Northbound horse.

They know that they have to pay the charges which I incur while using an “in network” facility, and the fact that the facility subcontracted some of the work is irrelevant to the agreement that exists between the insurance company and me. The little tale about payment for “reading the tests” is invented out of whole cloth, a polite way of calling it a blatant lie, as a ploy to avoid paying the charge. They know very well that the charge is for the discount which an “out of network” provider does not allow, and they deny the charges in hopes that I will not challenge the denials.

The hint in their very first response to my challenge that they are willing to give in and pay it is one tip-off of my conclusion, and payment of the $835 charge is another. Many patients will not think to challenge bills under $150 when they are looking at a long list of bills which have been paid, but everyone is going to challenge a denial on a bill that large, and they know it. That signals to me very clearly a “We’ll deny these bills and see if we can get away with it” approach on the smaller bills.

Object lesson: don't hesitate to challenge insurance claim denials. Sometimes you win.