Cigna insurance did not cover my lab tests

[brandonsmith13]

Hello,

Apologies if this is long. I wanted to share all the details. I appreciate any insight or help I can get.

I just received a $533 bill for lab work I had done at the beginning of the month. I have Cigna Choice Plus PPO (Open Access.) I had made an appointment with a PA, as I had some concerning symptoms and was afraid I was diabetic and had general health concerns. It had also been a few years since seeing a doctor (so it was my first appointment with this clinic.) Once speaking with the PA about my symptoms and establishing care, she ordered labs to be completed. Multiple blood panels.

These were the labs as shown in my results: AC1, WBC, RBC, HGB, HCT, MCV, MCH, MCHC, RDW, plt, MPV, neut%, lymph%, mono%, eos%, baso%, lg%, NRBC%, neut#, lymph#, mono#, eos#, baso#, lg#, glu, BUN, crea, GFR, GFR afric, BUN/crea, Na, K, cL, CO2, Ca, TP, alb, glob, A/G, tbil, ALKP, AST, ALT, FSH, LH, ins, prol2, TSH, vitd, E2, prog, chol, HDL, trig, LDLC, chol/HDL, VLDL, HCV, 17-hydrox., anti-mullerian hormone (amh), testosterone

On my bill in my provider's portal, I see nine services listed. It seems as though there was a small "Insurance discount" applied to each aside from the "General Health Panel", but the majority of the lab costs were not covered (total cost was a bit over $700 before discounts.) This is what I see: Hemoglobin glycosylated a1c, Estradiol assay, Gonadotropin follicle stimulating hormone, Insulin total assay, Prolactin assay, Lipid panel, Progesterone, Gonadotropin luteinizing hormone, General health panel

Looking at my plan details, I am confused on my coverage. According to my plan summary, laboratory services for the Physicians services/office visits should be 100% covered without deductible or co-insurance, as well as independent labs and outpatient facility labs. I don't think it would fall under this, but preventative care including preventative labs should also be fully covered in network. However, looking at my Cigna portal, they seem to be treating 10/11 line items as not covered (but with discounts applied) and have said my payment of the bill will go towards my in-network deductible. In the bill, I do not see a breakdown of the types of labs either, just 11 line items titled "Laboratory."

Any help would be greatly appreciated. I have not done anything about this yet, as I wanted advice first.

 

[kgr13]

@brandonsmith13 The short answer is that the tests you are billed for were "covered" in accordance with your plan.

You are confusing "covered" with "free". The "free" preventative services are very limited and are listed specifically as they are required by the ACA.

Anything done beyond those specific tests is considered to be diagnostic and not preventative and so insurance covers it based on your plan,

If you look at your EOB it seems to have provided that - i.e. amount billed; amount of insurance negotiated rate; amount credited towards your deductible and amount you owe for each amount which is presumably the negotiated rate until you have hit your deductible amount,

 

[brandonsmith13]

@kgr13 Okay, thank you for the insight. I just took a look at my summary of benefits and coverage, and it says diagnostic tests (X-ray, blood work) has "no charge" for in network services and the deductible does not apply. In the exceptions/limitations column, it also lists "none."

I do see in the preventative column, it does say I may have to pay for services that are not preventative. But I was under the understanding that my labs were diagnostic, as I came in with specific symptoms and that's why the labs were drawn in the first place. Even if a few of them were preventative to establish care, many were related to my symptoms per my PA's orders.

Would there be any avenues to try and investigate this further?

 

[kgr13]

@brandonsmith13 Again, contact your insurance company since no one who doesn't have your plan in front of them can definitively advise you.

The fragments you are provided aren't enough - they state that you have to pay for services that aren't "preventative" but there is no charge for "diagnostic services"

Preventative is a term of art in the ACA and is limited to specific services. Under the ACA these must be provided free

 

[brandonsmith13]

@kgr13 Okay thank you, I am on the phone with the billing office for my PA and will contact insurance after if needed. It seems there may have been an error in the billing code and PA notes, so keeping my fingers crossed. I grew up on VA benefits as a dependent, so this is all a bit new to me.

 

[kgr13]

@brandonsmith13 Well hopefully for your finances, your insurance does pay for the tests you had without your deductible limiting it.

I am deliberately using "pay" instead of "cover" since many treatments can be covered but the insured still has to pay a lot because deductible isn't met

All anyone on the internet can generally advise is how plans generally work and it is typical that diagnostic tests are covered but subject to deductible.

OP might have a much better plan than is typical

 

[kgr13]

@brandonsmith13 VA eliminates all of the "games" that people have to endure with private insurance.

It is straightforward in terms of not having to pay for any care that is prescribed by the VA doctors.

My father was eligible for VA benefits although he wasn't a career soldier. He also had regular Medicare with a Medigap policy.

This was in the days before there was any coverage for prescription drugs through Medicare so he would go to the VA to be prescribed certain expensive drugs that he needed. So long as a VA doctor prescribed them, the VA pharmacy there would provide them for free.

He also got his hearing aids free from the VA.

He didn't use them for every day care because it was a bit of a drive for every day stuff which was covered by Medicare but he was always received great care and really liked all of the doctors and medical providers there. And he was receiving state of the art hearing aids that would have cost him thousands on the private market.

 

[nhaas11]

@kgr13 Wouldn’t “100% covered without deductible or coinsurance” in the plan summary mean they shouldn’t be subject to the deductible? Maybe I’m misinterpreting

 

[kgr13]

@nhaas11 You could call your insurance company for clarification.

I don't have adequate information since one needs to read the entire summary of benefits and you are just providing a fragment of a sentence without context.

There could be limiting language in terms of what tests are covered without a deductible or co-insurance as typically all tests are subject to co-insurance and/or a deductible EXCEPT for those which are legally designate as "preventative" pursuant to the ACA.

I can only provide what would be typical for most insurance plans with a deductible - especially since your EOB seems to explicitly state that there was a plan negotiated rate and that the amount you owe is because of the deductible of your plan.

There also seems to be something called General Health Panel - was this covered 100% or subject to the deductible.

But again you would need to discuss this with your insurance company as you could have a plan that is different than the norm.

 

[one_who_seeks_light]

@brandonsmith13 Did you have your blood work done in house through the providers associated hospital OR was it done at an independent group such as Quest, Labcorp?

Assuming it stayed in house, that could be another reason for sticker shock.

 

[acruthers]

@brandonsmith13 Many of these tests are not routine tests. They are often used to investigate fertility issues so maybe the PA did not put in the right CPT codes to justify them.

 

[brandonsmith13]

@acruthers Thank you. Yes, some of my symptoms suggested PCOS/hormonal issues, so she included this marker testing to potentially move towards a diagnosis. After getting off the phone with billing, it sounds like insurance may have denied coverage under diagnostic testing (which should be no cost and no deductible) because there was not the right code and justification for testing. It seems they had already put the bill on hold prior to me calling and have now opened a case with my insurance and are having my PA review. So, hopefully all will be resolved once that is updated!

 

[mewmewpanda]

@brandonsmith13 That's good!

 

[resjudicata]

@brandonsmith13 can you update us on the right code? i have the same insurance

 

[manoffear]

@brandonsmith13

laboratory services for the Physicians services/office visits should be 100% covered without deductible or co-insurance

What KIND of lab services, though? A lot of medical insurance will cover diagnostic but not screening lab tests. If you have a test to determine if you have something or not, that is usually coded as a screening test, while a test to adjust medication for example would be a diagnostic or medical test.

IF your insurance is through your employer AND the employer is large enough to have to provide ACA-compliant insurance (e.g. 100 employees or more), ACA requires certain preventive tests that are covered even though they are screening tests.

Do you have a deductible on your plan? Perhaps you have not yet met your deductible so that nothing is paid until the deductible is met.

 

[christdriven1983]

@brandonsmith13 Your plan will have an appeal process. Do that. It might be that your physician used a " wrong" diagnosis code

 

[novictoryagainstmordor]

@brandonsmith13 Follow the appeals process. In my state, you can file a complaint with the state insurance department if the insurance policy is regulated by the state (i.e., your insurance card has "DOI" printed on the front).

 

[prettypeacock1]

@brandonsmith13 These are diagnostic and not preventative.

 

[mrmovie1983]

@brandonsmith13 Your tests were covered. Because they were diagnostic and not preventive, the cost will count towards your deductible. They were diagnostic because they were meant to aid in the diagnosis of PCOS. Very few tests are “free” on the preventive side and require specific preventive diagnosis codes, which were not used in this case. Your Dr did nothing wrong; insurance co did nothing wrong.

 

[jander8629]

@brandonsmith13 Verify: CBC w/ diff, CMP, FSH, lh, lipid panel, tsh, insulin? Prolactin? (Prol2) E2? Estradiol, 17 hydroxyprogesterone, hep c? Amh, testosterone lcms or immunoassay?