Insurance Alert

Unexpectedly, some insurances are distinguishing at what level they cover “screening or well care”, eg. physicals with screening labwork; screening bone densities, versus “symptom oriented/sick visits” and diagnostic tests and labwork to evaluate a problem (for example, weight gain visit with a thyroid blood test; or fatigue visit with a blood count).

Some insurances have a preventative allowance.  In that case, it makes sense that annual physicals and all labwork and testing done at that time be coded as “SCREENING”.   Bone densities done as screening may also be coded as such.

Other insurances cover routine physicals and screening labs differently: they may apply the full amount to your deductible, or they may not cover routine screening labwork. If screening labwork is NOT covered, your insurance company may or may NOT negotiate pricing on your behalf.

If your insurance doesn't cover routine blood work, but negotiates a price with the lab on your behalf, routine screening lab work may be inexpensive.  IF NOT,  routine screening blood work, that costs $35 at the 9 Health Fair every April, may cost you as much as $400.   

We have no way of knowing how to code your visits or labwork, other than to be as honest as we can.

For example, you may come in for your routine physical, and we code it as such. However, it might seem reasonable to us to code the labwork done at the time of your routine physical with a diagnosis code that applies to you, for example, if you have “hypothyroidism” or “high cholesterol” or “family history of heart disease.”

If your insurance has a well benefit, they may not include the lab work as part of that because it was coded with a diagnosis other than “screening.”  If you don’t have a well benefit, they may NOT cover it unless there is a diagnosis code other than “SCREENING.”

We have no way of knowing the rules of YOUR insurance.   We have recently had many problems because coverage is changing,  each insurance has it’s own policies, and there is a tremendous lack of accessibility to coverage information.  There is no transparency in lab pricing like for example, in car sales, where there is a MSRP or “ manufacturers suggested retail price.”

If we do lab work or tests and we use a diagnosis code, however appropriate, you insurance may or may NOT pay. We simply can’t predict.

YOU MUST GET THE INFORMATION ON THIS ISSUE  BEFORE YOU COME IN and tell us whether it would be better for you if your labwork or tests are sent in as  screening test or a with a diagnosis or whether it doesn’t make any difference.    

Obviously, we are not going to put ourselves at risk of fraudulent billing.  However, often we can justify testing or labwork as Wellness or Screening or alternatively, use an appropriate code.

If you do not know which is better and cannot guide us, we will bill in the most honest way possible.  If you schedule a physical or “well exam” it will be coded as such, and any labs done at that time will be coded as screening, even if you have diagnoses, UNLESS YOU TELL US OTHERWISE.

WE CANNOT CHANGE THE CODES ONCE THE BILL GOES OUT. WE CANNOT  HOLD BLOOD IN THE LAB.  YOU MUST KNOW AT THE TIME OF YOUR VISIT IF THIS IS AN ISSUE FOR YOU.