money spelled out in scrabble letters on dollar bills
Published on Flickr by 401(K) 2012, via Wylio

It’s a medical billing story with a happy ending.

The share on our software for a Pap smear associated with a woman’s annual exam said the New Orleans area woman was charged $247, and she had to pay.

She said this:

“The yearly exam was covered. I choose the doctor because she was in my plan. The doctor’s office sent the regular pap smear to a doctor in New York. I appealed the denial of claim that was based on the test being done out of state/out of coverage area but they denied my claim. After reading small print on patient information on [the doctor’s]  website, it notes that they use three providers for tests, one being Quest (which is an approved lab) but the other two were not familiar. As I used my insurance, I wrongly assumed they would use Quest. I can only assume the doctor gets a kick back on sending tests to this out of state/out of network doctor. No other reason why. Will never go to this doctor again.”

She left an email, and at our suggestion, our partners at WVUE Fox 8 News replied:

‘My colleagues on the data team are wondering whether you have phoned the doctor’s office to object and ask them to assume responsibility?”

She answered:

“No because I’m sure I know the response will be – We told you to check the lab companies we use in our patient information section. I have copied and pasted what is posted on page two of their financial notice which I actually read but when I saw Quest Diagnostic, I assumed they would use them since they are in state and in my plan. They did not ask me which provider to use or if I called each one.

“Laboratory and Diagnostic Policy

“It is the responsibility of the patient prior to being seen by the provider as to what specific coverage you have with your current insurance plan and if it includes laboratory or diagnostic testing.

“Please note that insurance companies are contracted with the laboratories for prices and coverage therefore [the doctor] would not have access to your specific information regarding laboratory testing.

“It is your responsibility to inform us at the beginning of each appointment if your insurance is not
accepted by any of these labs.

“The following lab services have been contracted for use by [the doctor] but are not
associated with [the doctor]:

“Quest Diagnostics ‐ (800)759‐2758 MDL ‐ 877‐269‐0090 Women’s Health Lab – (855) 823‐7277

“For your convenience, we have included the phone numbers of the labs that we use if you should have any billing questions for laboratory services provided.

“Each laboratory is responsible for billing patients for laboratory services rendered.”

The happy ending: She’s got $247 more in her pocket

She then wrote:

“Ok. I went ahead and called the doctor’s office just in case there was anything they could do and was asked to leave a message for the nurse. They confirmed that they ‘should’ have used Quest but they did not. I am waiting on the nurse to call me back to explain why they did not and whether they will ask the out of state lab to dismiss the charge. I will update you once I find out more.”

She then wrote:

“I wanted to update you on the billing situation I experienced. I received a call last night from the nurse at the doctor’s office who stated they were going to call the out of state lab to find out what happened. This am I received a call from Women’s Health Labs who stated that my specific insurance through Humana is the ‘one off’ plan that kicks back their bills due to being ‘out of plan’. Several other Humana plans and other insurance plans will cover them or they appeal the first denial and usually they are approved. In cases such as mine, they will ask the insurance company to appeal the decision based on the fact that the patient did not request an out of state provider and that they are usually approved. Whether they get paid by Humana will be between them and Humana. Either way, due to my insurance being one of the few that kick them back, they assured me they make exceptions for that and that I will never receive a bill from them for these tests. Both the doctor’s office and the lab representative were very helpful and kind. I called the doctor’s office back this am and let them know I am totally satisfied and thankful with the response I received.

“From this experience, I learned that actually calling the insurance company and the doctor’s office and asking for an explanation (coding, etc) can actually resolve a problem. I was cynical that they would be helpful and was pleasantly surprised.”

Lessons learned: Read the paperwork. Never assume anything. Get it all in writing. And: Appeal, and keep appealing.

Jeanne Pinder

Jeanne Pinder  is the founder and CEO of ClearHealthCosts. She worked at The New York Times for almost 25 years as a reporter, editor and human resources executive, then volunteered for a buyout and founded...