4 ms·

I have good health insurance but recently my insurance declined payment for a lab test on grounds it was experimental. Turns out the insurance company was on so

I have good health insurance but recently my insurance declined payment for a lab test on grounds it was experimental. Turns out the insurance company was on solid grounds. At this point I was on the hook for the lab fees. But here’s the interesting part: because the insurance declined payment, negotiated rates no longer apply. This means the lab gets to charge me list price. The list price is a random high price that has no relation whatsoever to reality. In my case I was charged 3x the negotiated price! This executive order helps people in my situation—you can argue that the list price is unreasonable and that the negotiated price is all you should have to pay (even though you were not party to the negotiation). This executive order is also useful for uninsured patients because you now have a basis for arguing for a lower bill. And the courts would be sympathetic because everyone knows list prices are random numbers!

sbov 7y ago
I ran into a similarly infuriating issue with a hospital. We have insurance. But we knew the procedure wasn't covered by insurance. So we would get the list price. We asked about the cash price. But they said we couldn't get the cash price because we have insurance. They said that you cannot get the cash price if you have insurance because the hospital requires procedures always go through insurance if you have it. But we could lie and claim we don't have insurance. On the day of the procedure, they said, oh, if we bill it like this, your insurance would cover it! Sounded good to us. They were wrong. So we ended up with the list price.
- jachee 7y ago
  If you know your insurance won't cover a procedure, couldn't you truthfully tell them that you don't actually have insurance for that procedure?
  - observer12 7y ago
    Most times its not definitive if the insurance will cover a procedure until after. I know for myself there is a fairly "cosmetic" produce I want, but no matter which surgeon or insurance I have I can't get an answer from either that isn't basically, "do the procedure and after it will be determined if its covered". While the procedure isn't life threatening it definitely would be quality of life improving. Unfortunately, its generally considered cosmetic, at least until later in life where the side effects of not having the procedure can become life threatening.
subhobroto 7y ago
EXACTLY! Your only choice is to change your employer or decline your employer provided insurance if you wanted to join an network that's receptive of your tests. Just because InsCo1 treats a lab test as experimental does not mean InsCo2 treats the same lab test as experimental. In your last sentence though, you seem to assume publicly listing prices would lead to a lower bill I wrote a response to this article here: https://news.ycombinator.com/item?id=20281150 https://news.ycombinator.com/item?id=20281150 Would love any input!
- flowerlad 7y ago
  If you are uninsured and receive a medical bill, unless the price was agreed upon before the medical procedure, you can go to court to argue that the bill is not fair or reasonable. List prices are random numbers. Having access to the actual prices paid by insurance companies helps you make your case in court as to what a realistic price should be.
  - subhobroto 7y ago
    > Having access to the actual prices paid by insurance companies helps you make your case in court as to what a realistic price should be That's not public information. Even if that was available, that's useless. Realistic price does not matter at all unless we are talking millions of dollars. Being in network or not does. Let me explain why: Have you been to court on this matter? I am interested in what your experience was. Here is mine: the judge was tired from the previous case and really did not care what I nor the ambulance provider thought. To her we were just sqabbling over prices: The ambulance provider wanted way more ($6k vs $600) than I thought was reasonable and I felt I had been taken advantage of when I was most vulnerable and it was not a honest way to make a living and we should not encourage it. The judge had no interest in how I felt: it was all a matter of how to get us out both quickly and have the next hearing. The ambulance provider said their 2 mile trip to the ER was worth $6k because blah blah blah. Then I presented. I had printouts that showed that ambulance providers that were in network with my plan typically charged $550 for the same exact service with the same level of staff in the ambulance. I was hopeful that showing this and that there was no in network ambulance providers within a reasonable distance where I was injured would help me. Nope. I also said it was pretty unethical for the ambulance provider to have a business plan where they would be out of network by design with all insurance companies as way to extract as much as they could from people in distress. I was with Anthem Blue Cross - they are a pretty big company, no small fish. This ambulance provider clearly puts it on their website and all paperwork that they explicitly don't work with insurance companies because they don't get paid a fair price. The judge asked me if I had signed the paperwork that said I would bear all expenses before I got into the ambulance. I said yes. Then she asked how much money I made and what payment plan I would be able to afford. Maybe if the ambulance charged me a million dollars, then I could try with the "bill is not fair or reasonable" story, but I had the feeling the ambulance could have charged me $10k and I would have had to pay it because I'm a highly compensated individual in the top 1% income bracket in the country so I deserve to pay more. I now always carry blankets and bags in my car so I can cover myself if I am bleeding and get into a taxi or Uber/Lyft/etc, without getting blood on the seat, to the nearest hospital if I can.
michaelmrose 7y ago
You could have refused to pay and offered them the original price or threatened to sue which you can do without benefit of a lawyer. The act of litigating it would almost certainly be higher than any differential.
- blackflame7000 7y ago
  That’s what I did after a surgical center told me that they spoke with my insurance company and everything was fine only to later send me a bill for $150,000 for a 1hr surgery to fix a broken hand. How are you supposed to deal with in-network / out of network hospitals when you have a bone coming through your hand? It eventually went away because balance billing was made illegal in california.
- flowerlad 7y ago
  Simply refusing to pay or ignoring the bill results in the bill being sent to collection and your credit will be impacted. The only thing the lab was willing to do was to put me on a payment plan. In the end I didn’t pay a penny. I have good insurance so if they declined payment that must be for a good reason. So I researched that angle. It turned out that the test the doctor ordered was FDA approved, but not as a cancer screen, which is what the doctor ordered it for. I threatened to sue the doctor for malpractice, and she worked with the manufacturer of the test and the lab and made the bill go away. The manufacturer was pushing the test as a cancer screen, but the doctor should have checked if it was FDA approved as a cancer screen.

sbov 7y ago

I ran into a similarly infuriating issue with a hospital. We have insurance. But we knew the procedure wasn't covered by insurance. So we would get the list price. We asked about the cash price. But they said we couldn't get the cash price because we have insurance. They said that you cannot get the cash price if you have insurance because the hospital requires procedures always go through insurance if you have it. But we could lie and claim we don't have insurance. On the day of the procedure, they said, oh, if we bill it like this, your insurance would cover it! Sounded good to us. They were wrong. So we ended up with the list price.

jachee 7y ago
If you know your insurance won't cover a procedure, couldn't you truthfully tell them that you don't actually have insurance for that procedure?
- observer12 7y ago
  Most times its not definitive if the insurance will cover a procedure until after. I know for myself there is a fairly "cosmetic" produce I want, but no matter which surgeon or insurance I have I can't get an answer from either that isn't basically, "do the procedure and after it will be determined if its covered". While the procedure isn't life threatening it definitely would be quality of life improving. Unfortunately, its generally considered cosmetic, at least until later in life where the side effects of not having the procedure can become life threatening.

subhobroto 7y ago

EXACTLY! Your only choice is to change your employer or decline your employer provided insurance if you wanted to join an network that's receptive of your tests. Just because InsCo1 treats a lab test as experimental does not mean InsCo2 treats the same lab test as experimental. In your last sentence though, you seem to assume publicly listing prices would lead to a lower bill I wrote a response to this article here: https://news.ycombinator.com/item?id=20281150 https://news.ycombinator.com/item?id=20281150 Would love any input!

flowerlad 7y ago
If you are uninsured and receive a medical bill, unless the price was agreed upon before the medical procedure, you can go to court to argue that the bill is not fair or reasonable. List prices are random numbers. Having access to the actual prices paid by insurance companies helps you make your case in court as to what a realistic price should be.
- subhobroto 7y ago
  > Having access to the actual prices paid by insurance companies helps you make your case in court as to what a realistic price should be That's not public information. Even if that was available, that's useless. Realistic price does not matter at all unless we are talking millions of dollars. Being in network or not does. Let me explain why: Have you been to court on this matter? I am interested in what your experience was. Here is mine: the judge was tired from the previous case and really did not care what I nor the ambulance provider thought. To her we were just sqabbling over prices: The ambulance provider wanted way more ($6k vs $600) than I thought was reasonable and I felt I had been taken advantage of when I was most vulnerable and it was not a honest way to make a living and we should not encourage it. The judge had no interest in how I felt: it was all a matter of how to get us out both quickly and have the next hearing. The ambulance provider said their 2 mile trip to the ER was worth $6k because blah blah blah. Then I presented. I had printouts that showed that ambulance providers that were in network with my plan typically charged $550 for the same exact service with the same level of staff in the ambulance. I was hopeful that showing this and that there was no in network ambulance providers within a reasonable distance where I was injured would help me. Nope. I also said it was pretty unethical for the ambulance provider to have a business plan where they would be out of network by design with all insurance companies as way to extract as much as they could from people in distress. I was with Anthem Blue Cross - they are a pretty big company, no small fish. This ambulance provider clearly puts it on their website and all paperwork that they explicitly don't work with insurance companies because they don't get paid a fair price. The judge asked me if I had signed the paperwork that said I would bear all expenses before I got into the ambulance. I said yes. Then she asked how much money I made and what payment plan I would be able to afford. Maybe if the ambulance charged me a million dollars, then I could try with the "bill is not fair or reasonable" story, but I had the feeling the ambulance could have charged me $10k and I would have had to pay it because I'm a highly compensated individual in the top 1% income bracket in the country so I deserve to pay more. I now always carry blankets and bags in my car so I can cover myself if I am bleeding and get into a taxi or Uber/Lyft/etc, without getting blood on the seat, to the nearest hospital if I can.

michaelmrose 7y ago

You could have refused to pay and offered them the original price or threatened to sue which you can do without benefit of a lawyer. The act of litigating it would almost certainly be higher than any differential.

blackflame7000 7y ago
That’s what I did after a surgical center told me that they spoke with my insurance company and everything was fine only to later send me a bill for $150,000 for a 1hr surgery to fix a broken hand. How are you supposed to deal with in-network / out of network hospitals when you have a bone coming through your hand? It eventually went away because balance billing was made illegal in california.
flowerlad 7y ago
Simply refusing to pay or ignoring the bill results in the bill being sent to collection and your credit will be impacted. The only thing the lab was willing to do was to put me on a payment plan. In the end I didn’t pay a penny. I have good insurance so if they declined payment that must be for a good reason. So I researched that angle. It turned out that the test the doctor ordered was FDA approved, but not as a cancer screen, which is what the doctor ordered it for. I threatened to sue the doctor for malpractice, and she worked with the manufacturer of the test and the lab and made the bill go away. The manufacturer was pushing the test as a cancer screen, but the doctor should have checked if it was FDA approved as a cancer screen.