In January of this year, I had lab work performed as part of a follow-up to a physical exam. It was nothing out of the ordinary and represented a series of blood tests ordered by my doctor. I had the tests, attended my doctor’s follow-up appointment and that was that. I did not think much else of it until February when payment for several of the tests was denied by my insurer.
On February 14th, my insurer accepted and paid for two of the five tests performed. They denied three others, resulting in my owing the lab $267.71. The reason for the denial was listed on my Explanation of Benefits (EOB) as:
O8 – PAYMENT FOR THIS SERVICE IS DENIED. A NETWORK PROVIDER MAY NOT BILL YOU UNLESS YOU GAVE WRITTEN PERMISSION BEFORE YOU RECEIVED THE SERVICE. THE SERVICE IS NOT COVERED BECAUSE YOUR PLAN ONLY COVERS PROVEN PROCEDURES. THIS SERVICE IS UNPROVEN FOR THE DIAGNOSIS OR PROCEDURE CODE BILLED. IN ORDER FOR THIS SERVICE TO BE CONSIDERED FOR COVERAGE, YOU OR YOUR PROVIDER MUST SUBMIT SCIENTIFIC EVIDENCE THAT SHOWS THIS SERVICE IS SAFE AND EFFECTIVE FOR YOUR CONDITION.
This was a bit unusual, as the tests being performed were nothing unique or out of the ordinary. We will mention for future reference that the EOB was 7 pages long. A bill from the lab was received the following week.
Thus began a 5-month odyssey that only reaffirms the notion that the entire medical billing scheme in this nation is broken, and that very little common sense exists within the system today.
In a series of phone calls and follow-ups, my insurer recommended I contact my physician to have him check the medical coding used for those particular tests. This was not exactly the issue of highest priority for me, and it certainly became apparent over time that it was not one for my doctor’s office, either. My doctor works for a large medical group, and his office can only be kindly described as sometimes a nightmare to deal with. Meanwhile, as time wore on, I received several (increasingly less friendly) reminders that the lab expected a payment of $267.71.
It was getting to the point where it was apparent that the bill just needed to be paid. Short of the support needed from the medical and insurance communities, that bill was ultimately my obligation. But then, on May 31, my doctor’s office miraculously came through and resubmitted the coding to my insurer. On June 16, the bill was accepted, a network discount applied, and payment was made on my behalf.
And what was actually paid after all this time and effort? Well, the discount applied was $244.09. My insurer then paid the remaining obligation of $7.63.
We have to ask: What is the true cost of that $7.63 bill?
Certainly, the lab had to document and send that initial billing. The insurer had to process that bill, issue and justify its rejection. They also generated that 7-page EOB. I spent a good deal of time on the phone (most of it on hold) with my doctor’s office. I even had to physically drive a copy of the bill to the physician’s office for it to be reviewed. Several follow-up billings were processed and mailed. All because my insurer initially rejected a bill that would have required a $7.63 expenditure.
If this sounds sane to anyone, please explain the logic to me.
Most assuredly the lab would have been better off if we had not pursued a clarification. They would no doubt have preferred an out-of-network payment of $267.71 to the paltry amount they were otherwise entitled. We all complain about the cost of medical care today, but, in the world of general health, that cost seems to be obfuscated with a system of discounts and exemptions that befuddle the mind. True, the process saved me $267, but is any of this actually real?
Reviewing a series of EOB’s for just lab work for my wife and I over the last few years, I found that the insurer has been billed a total of $2870.03. After discounts, they paid $49.16. We paid $82.81. Are we certain medical care is that expensive? Or is the expense partially generated by all of the juggling balls being kept in the air around medical billing? Would a simpler, open rate billing structure ultimately reduce both complexity and cost?
We’ll probably never know. We do know, however, that 5 months of effort over a seven-dollar bill doesn’t feel worthy of the effort, nor does it justify the actual cost to all parties involved.