I Have A Serious HMO Problem

Last April, I went to my doctor because I had a skin rash. It was a routine visit. It was my first visit to this doctor, and he wanted to run some routine blood and urine checks. I had HMO coverage at the time, and the doctor was in my HMO plan. My total co-pay was $10.

A month later, I get a bill from the lab that did my blood and urine test. It was for over $400!!!! I sent the bill to my HMO, and lo and behold, they're not covering it. Also, part of the bill that I got from doctor included a charge for pathology which was covered by the HMO.

On Monday, I have to call my HMO claims center to sort all of this out. It looks like I'm getting charged for pathology from both my doctor and this lab.

Can someone tell me if I'm going to have to pay this lab bill? The doctor never mentioned that this was an additional charge. Shouldn't the HMO pay this bill? Can someone help me here?

But I will say this,,,the pathologists fee is separate than the lab..one is for tests the other is for interpretation...under normal circumstances they should both be covered if they were a medical necessity and ordered by your primary care physician...did you go outside the network at all?

My other advice is if you want to PM me the lab fees, (i.e. the test names and fees they charged per test)I'll look it up on my work computer on Monday (no doubt there is some duplicative billing in there and the fees were higher than what Medicare will pay) I can give you the info that would most likely knock off a significant chunk of that bill..thereby enabling you to negotiate with the lab to reduce the billing...more likely than not it's about 50 - 60% higher than what they would ordinarily get (based on my past experience.)

I did not go outside of my primary care network, and my physician ordered the tests. In fact, I had not gone to my physician for these tests, rather I went because I had a rash. The physician suggested these tests because it wsa the first time that I had gone to him.

The lab didn't send me a detailed breakdown of the bill, but I can probably get one from them.

my offer stands

On Monday, I will call both my HMO and the lab to demand an accurate bill. Then, I will call my doctor to find out what the hell is going on.

me a card listing their participating labs. When I go to a participating Dr. I must take the responsibility to make sure they use one of these labs. If not, I pay.

My HMO never sent me such a card. They just sent me a listing of the doctors in my network. My doctor never even told me what lab he was sending my stuff to? How am I supposed to know? How am I responsible for every little thing that my doctor does or does not do?

Most of the time they send a notice that they're refusing the claim. The first few times I called and complained and they just said they would go ahead and pay it.

Now I just throw the notice in the garbage. I think it's a game they play to see if you're naive enough to pay it without a fight.

They also tried to get me to pay a $900.00 lab bill because it didn't go to an approved lab.

I told them "That's between you and the Primary Care Doc, not on me"

They paid.

I'll let you all know how things turn out.