In May, 2020, my gastroenterologist ordered a specialized blood test, “Anser ADA” (it checks for antibodies to, and blood levels of, Humira, a biologic medication). His office gave me the order for this test on a form printed by Prometheus Biosciences, the company that performs this test. The form gives the lab instructions for collecting blood for this test and instructions for how to send the sample to Prometheus for the lab test itself. My doc’s office told me their own hospital system didn’t collect blood for this test and they directed me to another hospital system in my area, one that does collect for this test.
I called that other hospital system to check that they do in fact collect blood for this test and mail it off to Prometheus. I was told that they do. I asked for the price of this test. I was quoted a pretty high number ($700, at least). I was also told they didn’t know whether my insurance, Anthem Blue Cross, would pay for the test. I called Anthem BC and was told they did not cover this test because they consider it to be experimental. (I won’t get into that particular issue here.)
I’ve been out of work because of COVID and the medical conditiom treated by the Humira, so $700+ was going to be a big stretch. I called Prometheus, explained that my insurance won’t cover the test, and asked whether they have a patient assistance program. The woman I spoke with said that when they bill a BC policy and get a rejection, they automatically waive the cost of the test, so I would owe nothing. She also explained that the hospital system I mentioned has supplies of Prometheus’s own collection and mailing “kits,” with envelopes and postage-paid labels to use in sending the blood samples to Prometheus.
I went to that other hospital system’s lab, handed them my doctor’s order written on the form from Prometheus Biosciences, and got the blood drawn. One week later, the results were reported to my doctor. I didn’t get a bill or an EOB so I assumed Prometheus had waived the cost after getting a rejection from BC.
Fast forward to seven months later. This week, I got a bill for the test from the hospital system’s lab. It shows they billed BC several times and each time the claim was rejected by BC. I called the Lab Billing office to ask why the blood sample had been tested in their own lab rather than being sent to Prometheus as per the doctor’s order slip, and as I’d been told it would be. The person I talked to didn’t know why the sample hadn’t been sent to Prometheus. She said their lab had called my doctor’s office for his permission to run the test in their own lab and he had given that permission. I called my doctor’s office. They have no record of giving that permission.
It seems pretty self-serving of the hospital’s lab to have done the test themselves rather than following the instructions on Prometheus’ order form. I’d understand if they charged me a collection fee to draw the blood, however they charged me for collection AND the test itself. I would not have a bill for the test if they had followed the order form’s instructions to send it to Prometheus (and they have the mailing kits to make this easy), and my doctor’s office has no record of being contacted for the doc’s approval to process the test “in house.”
I still have not received an EOB from BC.
I want to contest the bill with the hospital system – I think I shouldn’t have to pay anything other than the collection fee. Other than writing a letter with the sequence I gave here, are there any laws or regulations regarding physicians’ orders, insurance billing, etc, that I can cite? Any other tips for contesting this? Thanks very much.
submitted by /u/Janezo
[link] [comments]
In May, 2020, my gastroenterologist ordered a specialized blood test, “Anser ADA” (it checks for antibodies to, and blood levels of, Humira, a biologic medication). His office gave me the order for this test on a form printed by Prometheus Biosciences, the company that performs this test. The form gives the lab instructions for collecting blood for this test and instructions for how to send the sample to Prometheus for the lab test itself. My doc’s office told me their own hospital system didn’t collect blood for this test and they directed me to another hospital system in my area, one that does collect for this test. I called that other hospital system to check that they do in fact collect blood for this test and mail it off to Prometheus. I was told that they do. I asked for the price of this test. I was quoted a pretty high number ($700, at least). I was also told they didn’t know whether my insurance, Anthem Blue Cross, would pay for the test. I called Anthem BC and was told they did not cover this test because they consider it to be experimental. (I won’t get into that particular issue here.) I’ve been out of work because of COVID and the medical conditiom treated by the Humira, so $700+ was going to be a big stretch. I called Prometheus, explained that my insurance won’t cover the test, and asked whether they have a patient assistance program. The woman I spoke with said that when they bill a BC policy and get a rejection, they automatically waive the cost of the test, so I would owe nothing. She also explained that the hospital system I mentioned has supplies of Prometheus’s own collection and mailing “kits,” with envelopes and postage-paid labels to use in sending the blood samples to Prometheus. I went to that other hospital system’s lab, handed them my doctor’s order written on the form from Prometheus Biosciences, and got the blood drawn. One week later, the results were reported to my doctor. I didn’t get a bill or an EOB so I assumed Prometheus had waived the cost after getting a rejection from BC. Fast forward to seven months later. This week, I got a bill for the test from the hospital system’s lab. It shows they billed BC several times and each time the claim was rejected by BC. I called the Lab Billing office to ask why the blood sample had been tested in their own lab rather than being sent to Prometheus as per the doctor’s order slip, and as I’d been told it would be. The person I talked to didn’t know why the sample hadn’t been sent to Prometheus. She said their lab had called my doctor’s office for his permission to run the test in their own lab and he had given that permission. I called my doctor’s office. They have no record of giving that permission. It seems pretty self-serving of the hospital’s lab to have done the test themselves rather than following the instructions on Prometheus’ order form. I’d understand if they charged me a collection fee to draw the blood, however they charged me for collection AND the test itself. I would not have a bill for the test if they had followed the order form’s instructions to send it to Prometheus (and they have the mailing kits to make this easy), and my doctor’s office has no record of being contacted for the doc’s approval to process the test “in house.” I still have not received an EOB from BC. I want to contest the bill with the hospital system – I think I shouldn’t have to pay anything other than the collection fee. Other than writing a letter with the sequence I gave here, are there any laws or regulations regarding physicians’ orders, insurance billing, etc, that I can cite? Any other tips for contesting this? Thanks very much.
submitted by /u/Janezo [link] [comments]Read Morer/HealthInsurance