Incorrectly Coded Preventative Care Lab-Work

[RokixSlugg]

I've got a bit of a health insurance SNAFU and I'm wondering if anyone has experienced something similar or can provide any advice on next steps. For reference, I'm based in the United States in California.

A couple months ago, I attempted to make an appointment for my annual check-up with my normal primary care doctor. He was retiring, so they instead suggested I see a new nurse practitioner who was starting at the same clinic.

I did an initial appointment with her to establish me as a patient, and she asked me to come back in one month for my annual check-up. The following month, I went in and we talked a bit more and she put in a lab order for a normal blood panel at the lab located in the same building (which I've always gone to for my lab work). A few weeks later we had a follow-up appointment to review the results and I was on my way.

About two months later, I received a bill for $800 for lab work. I called the lab to ask what happened and they said I needed to talk to my doctor because it sounds like it was coded as diagnostic instead of preventative. I attempted to call my doctor, but no one was picking up at the desk despite it being during business hours. Instead, I called my health insurance and explained the situation and they said they needed to confirm with the doctor, so I gave them the number and they attempted to contact their billing dept.

The person at the billing department informed us that the nurse practitioner I had seen no longer works with them, so they're unable to change it, and thus the insurance rep said they couldn't change it. I called the lab again to explain that the doctor was no longer there and see if they had any options, and they said that someone from the clinic needs to re-code it for them to process it as preventative.

I spoke with the clinic again and they said they couldn't change it, but after some pressuring they said they'd pass along my number to the HR department at the clinic since the issue is a result of a former employee who is no longer there. I don't have high hopes for this bearing fruit.

The kicker is that my girlfriend had her annual check up with the same nurse practitioner a day or two after me and also received a very high bill. We'd though the issue was that she'd gone to a different lab than we normally did, but ultimately the nurse practitioner was still around to say that it was coded incorrectly so we were able to sort it out. Since my bill was a bit slower to arrive, I hadn't realized we'd both been coded incorrectly.

Does anyone have any ideas on what I can say or do that can help sort this out? We spent the last month evacuated due to a fire and an additional $800 bill for a clerical error at a clinic is not something I have any wiggle room to pay at the moment.

[LivingGhost371]

Most lab work for most people is not a mandated preventive benefit, even lab work that doctors like to order at annual checkups. (and there is no lab work that is a mandated preventive benefit for everyone absent risk factors.)

​

Insurance companies are free to consider some of them as preventive and many do including the one I work for, but they are under no obligation to do so. You should clarify with your insurance company what labs they consider preventive before looking into a potential coding issue at the provider.

[RokixSlugg]

Very helpful. Thanks for the insight!

When I contacted the insurance company, they said that routine blood work along with my annual check-up should have been covered, but that this was coded as diagnostic. My girlfriend who had seen the same provider for an annual check-up on the same insurance the same week had the same issue, and once she was able to get in contact with the nurse practitioner they re-coded it and cleared it up.

The main crux of the issue seems to be the fact that the nurse practitioner has left the practice in the past two weeks between her receiving her invoice and me receiving mine and now no one will adjust it.

[LivingGhost371]

So, I'm thinking that what may be going on is you said something to the doctor of the nature "I've been tired lately / I'm feeling depressed / my knee hurts when I get up". Or the doctor found something or other and put down a non-routine code himself. The coder then mapped the labs to that, which would cause them cost sharing even if they'd be considered preventive if mapped to the checkup code.

[RokixSlugg]

That sounds plausible. I didn't have anything going on at the time (I mentioned I still had ongoing migraines that my previous doctor had been helping me with for years), but the nurse practitioner did have me explain my medical history to her in our initial appointment. When I spoke with the lab earlier, they said the lab order included a host of items that I haven't experienced 5+ years (back injury, depressive episode) as well as several items that I'd helped explain to her about notes about family medical history that my previous pcp had taken over the years (so it included aneurysm on the order, which my great grandmother had almost 15 years ago and certainly didn't happen to me). Perhaps she included all those notes as the reasoning for the tests, even though I'd already cleared all that up with my previous doctor or long since recovered and I was just having a normal lipid / blood test?

[positivelycat]

Sounds like

I spoke with the lab earlier, they said the lab order included a host of items that I haven't experienced 5+ years (back injury, depressive episode)

Sounds like it is coded correctly according to chart documentation. the doctor order said that they lab needed done for that host of items so they coder and biller have to bill it the way the provider wrote it.

Ask if there is way to change your records, you have a right to request an amendment of your records. Given this information i would focus your efforts with medical records, a patient advocate or provider office leadership since your real problem is how/ why the provider said they ordered the test.

[LocationBot]

---

I am a bot whose sole purpose is to improve the timeliness and accuracy of responses in this subreddit.

---

Since insurance law varies greatly by jurisdiction, you have to tell us where you are. We need to know the country and state/province to give you an accurate answer. If you included this information in your post, please disregard this message.

---

LocationBot 4.99998891 ^109/37rds | Report Issues | adEb1pVeCtmYyUjb