Hi all - I am a 27M who has health insurance through work - blue cross blue shield of Massachusetts. I have the blue care elect preferred.
I went to the gastro a few weeks ago because I’ve been having stomach issues. They did blood work and sent me home with a stool sample kit. I did the “microbiology” test and dropped it off at a labcorp location over a month ago. I received a bill in the mail today for $819 because the microbiology test is not covered by my insurance.
My insurance was reviewed by the gastro 2+ times (when I submitted the form for the appointment & when I arrived for the visit) and labcorp reviewed my insurance when I checked in to drop my sample off. At no single point did anyone care to mention that this would be such a large charge that isn’t covered by my insurance - obviously I don’t know if they even knew but my insurance was looked at and checked a lot.
When checking the claim document for that visit it states “BENEFITS ARE NOT AVAILABLE BECAUSE THIS SERVICE EITHER DOES NOT MEET OUR MEDICAL TECHNOLOGY ASSESSMENT CRITERIA OR OUR MEDICAL POLICY GUIDELINES.”
Why would a microbiology test ordered by a gastro not be covered???
Is there anything I can do to fight this? I’m planning on calling my insurance and labcorp tomorrow morning but $819 is a lot and this sucks and the fact that there was no transparency sucks even more.
It’s not the provider’s office’s job to verify every charge they’re going to bill. That’s your responsibility as the patient. The office only needs to check if your insurance is active and if they’re in-network or accept your insurance if they’re out-of-network.
If you’re having problems with your poop, it might be helpful to ask your provider to prove that the lab test is medically necessary. They can appeal the insurance company’s denial or non-covered charge by showing that the test is necessary.
If your insurance approves the claim or reverses the denial, you’ll still have to pay the costs covered by your plan, including deductibles, co-pays, coinsurance, and other out-of-pocket expenses.
I agree in principle, but providers don’t do a good job of explaining how patients should ask these questions. Medical procedure terms can be confusing and used incorrectly by patients. Providers should give patients a list of CPT codes that will be used so they can ask their insurance company. CPT codes are less confusing than ‘stool sample,’ which could mean many different procedures.
Go to your insurance company’s website and find the ‘medical policy’ section. It might be hard to find because it’s usually for providers, but it’s there. Search for the test you had, then find the related policy. This will tell you under what conditions they’ll pay for it.
Remember what happened with Elizabeth Holmes and Theranos?
That’s why insurance companies don’t pay for every single test. Unfortunately, some doctors recommend tests that aren’t proven to be helpful or aren’t the best first option for investigating something.
I’m not saying your doctor was being paid off, but maybe they watched too many videos or read too many brochures about this test and forgot to do other tests that should be checked first. Unless you had clear signs of a parasitic infection, this probably wasn’t the right first test.
If your doctor really thinks this test is medically necessary and has evidence to support it, they can appeal to your insurance company and see if it will be covered. But this is a lesson that you should always question your doctors and understand what they’re trying to get you to do. Ask questions like ‘Is this the first test that should be done?’ or ‘What other tests do I need?’ You can even ask them ‘Have you asked my insurance if this test needs preapproval?’ These questions will help you make informed medical decisions instead of just trusting everything your doctor says.
It’s possible that the specific test they did is unproven, so it’s unlikely to be approved. Or maybe your doctor just didn’t prove that it was the right test to do at that time.
Insurance can be confusing. Not everything is covered. Many times, certain lab tests won’t be covered because another test should have been done first, or it’s considered unnecessary, not medically approved, or the insurance company doesn’t want to pay for it (like genetic testing).
A lot of times, these labs offer cash discounts. Sometimes they can cut the cost by 50 to 80%. I suggest calling them to see if they have any discounts.