Lab Billing Issues

As the financial transactions and communication between the insurance company (e.g. Aetna) and the lab company (e.g. Quest Diagnostics) are not under our control, you must deal with these companies directly. We have no influence over them.

Per the Affordable Care Act, routine preventive services must be covered 100% by your insurance company. Per the US CDC (Center for Disease Control), for Men who have sex with Men (this is the public health term doctors use), this includes Hepatitis A, B, C, Syphilis, and HIV screening, as well as Chlamydia and Gonorrhea screening of three anatomical sites: urine, throat, and rectal. The link from the CDC regarding this area is here: https://www.cdc.gov/msmhealth/for-your-health.htm

Insurance companies and their staff are often woefully uninformed (or at least claim to be) regarding standard care in this area, and routinely deny coverage. You must self-advocate, call them on their mistakes, and ensure they pay honestly. If they are dishonest, you must report them to NY State Department of insurance (see below).

A quick note about deductibles -- if the lab was indeed processed at in-network rates with a non-preventive code (i.e. a code other than Z00.00 or Z20.6), and the amount has been applied to your deductible, then you generally owe this money to the laboratory company. This is not an error. This is how a deductible works.

Moving onward, the most commonly seen billing issues are:

1. a lab charge associated with a Preventive Code (Z00.00, Z20.6, etc.) is incorrectly applied to your deductible amount, insurance doesn’t pay, and the lab asks you to pay

2. a lab is not processed “in-network” at all, the insurance doesn’t pay the lab bill, and the lab asks you to pay extremely high out-of-network rates

3. the bills/statements make no sense whatsoever and it is impossible to determine the reasoning behind the billing

Sometimes the mistake is the lab's fault, and sometimes it is the insurance company’s fault. Very often they are both in error. Very often the error is blamed on a "computer glitch.” They will blame each other, and often try to make you pay the bill. They will often use vague terms like "the doctor needs to use a different code," etc. which are fundamentally meaningless. The companies are not, for obvious reasons, incentivized to be helpful to you -- so one must push back.

Our office will always provide you with the correct code. For Preventive testing, the codes (ICD10 guidelines) Z00.00, Z20.6 or other Z codes are typically used.

One common example -- at our practice STI swabs are routinely done on different areas of the body. Each swab for each anatomical site has its own test code, and should be reimbursed independently. The insurance company and/or lab often make errors and consider this "one test, processed/billed two or three times accidentally", and the insurance company will not pay the laboratory bill. You must make both the laboratory company and the insurance company aware that in fact these are indeed separate, individual tests, for separate anatomical sites, and should each be paid individually. Should you call to complain, keep in mind the company representative has no medical training and very likely will have no idea what you are talking about.

If you run into these issues please use the sample letter below, and mail duplicate copies to both (1) Insurance company and (2) Laboratory company. Everything should be done in writing. Attach copies of invoices / statements / previous correspondence / EOBs (Explanation of Benefits). Expect a protracted paperwork effort.

If the issue is not resolved in a timely fashion, you should file a complaint with the NY State Department of Insurance here: http://www.dfs.ny.gov/consumer/fileacomplaint.htm

Sample Letter

Today’s Date:

Member Name:

Member Date of Birth:

Member Insurance ID:

Dear Insurance Company,

Date of lab service:

Name of lab company:

The laboratory above is "in-network" with your company and the tests drawn on above date of service need to be paid. I have discussed with my doctor's office and the codes are correct. Preventive services (as identified by ICD10 code Z00.00) should not go to deductible according to rules and regulations set forth by the Affordable Care Act. If this bill is not processed properly and paid according to ACA guidelines, I will submit a complaint with the NY State Dept. of Insurance.

Please see attached laboratory invoice/bill.

Optional: Per the Affordable Care Act, routine preventive services must be covered 100% by your insurance company. Per the US CDC (Center for Disease Control), for Men who have sex with Men, this includes Hepatitis A, B, C, Syphilis, and HIV screening, as well as Chlamydia and Gonorrhea screening of three anatomical sites: urine, throat, and rectal.

The link from the CDC is here: https://www.cdc.gov/msmhealth/for-your-health.htm

If this issue it not addressed within 5 business days, I will submit a letter of complaint to the New York State Department of Insurance within 10 business days from the date of this letter.

Sincerely,

Patient name

Patient address

Patient phone number