BCBS won't cover lab work? (x-posted)

[Champ715 207]

Hi all,

I had gastric sleeve surgery last September 2015. In August 2015, I had the pre-op blood work done at Quest Diagnostics. Shortly after that visit, I got a $1113 lab bill from Quest and they told me that BCBS wouldn't cover the costs because the surgeon's office had coded it to "obesity". I don't understand why BCBS will cover weight loss surgery but not the associated lab/blood work. I called my surgeon's office to explain this to them and the nurse told me she would change the billing code and resubmit to Quest. Well, apparently she never did that. I thought she did because months went by and I never heard another word about it. This past Monday I got the same $1113 bill from Quest again for the August 2015 lab work. I had post op lab work done in March and Quest says BCBS won't cover that blood work either because it was also coded to "obesity". Quest refuses to negotiate with me on the cost but says I can pay $25 each month until the end of time if I want to.

What baffles me is that I know I'm not the first person to have BCBS insurance and my surgeon's office sends everyone to Quest diagnostics for lab work. This cannot be the first time this has come up. The insurance coordinator at my surgeon's office said to be verbatim "it will be covered" and the nurse already told me once she would fix it but never has.

Has this ever happened to anyone else? BCBS said I had 180 days to appeal the first bill from August 2015 so I'm screwed on that one. I'm just trying to figure out what to do to get the March 2016 bill covered or negotiated.

Any suggestions or ideas would be greatly appreciated.

(Cross posted in the insurance forum)

[RickM 1,747]

"There's no reason for it, it's just our policy...."

You need to get back to the surgeon's office to get that coding changed, as that is where the problem apparently is. I can see that they don't cover it when coded as "obesity" as insurance often doesn't cover weight loss programs, though they will cover WLS. It needs to be coded as something acceptable (the surgeon's insurance coordinator should be up on this,) and still accurate, such as pre-op labs for covered surgery.

It reminds me of the days when routine annual physicals weren't covered (and may still not be by some companies) and you (doctor and patient collectively) had to establish a complaint as the excuse for the office visit and tests. It's all part of the game, unfortunately, and it seems that your surgeon's office isn't very good at playing it.

[NikkiDoc 312]

I would appeal it with BCBS anyway. Ask for the copy of the actual wording in the Policy they are denying it under.

While each BCBS is different and they each had many plans I had no problems with my pre-op blood work being paid by them.

I would raise Holy heck with the surgeon's and Quest about getting it rebilled with additional codes such as the ones for any co-morbidities such as high blood pressure, reflux, fatigue etc....

If BCBS refuses to provide the specific provision of the policy they are using to deny the claim you can file a complaint with your state's department of insurance. Sometimes that helps move things along even if your policy is self funded and not insurance.

[1excited 15]

I was sent to Lab Corp luckily the lady warned me I could be billed over 1,000 and with my insurance I need to go to Quest (thank goodness or I would be in the same boat)

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[kaitlynm 335]

The only way to get it covered is to get the surgeon to change the code. I went through this same thing with Drs appointments for my thyroid that got coded to obesity. Finally the Drs office changed the coding and resubmitted and it was covered. I would still try to fight it out on the Aug labs. You Surgeon should still be able to resubmit that with the right codes regardless of the time limit.

[Elle09 157]

Recommend you go back to BCBS and request a copy of your explanation of benefits (EOB) for the date you had the lab work done. You will want to review the the billing code that was used by the surgeons office when they submitted the claim to your insurance. I would have a discussion with them (BCBS) and find out under what circumstances do they cover for lab work. They will probably tell you but they may not provide the billing code. I would have a discussion with the patient coordinator in the surgeons office for assistance in resubmitting the paper work with a different billing code that is applicable.

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[Pillar2butterfly 391]

I have BCBS and something similar happened to me. Turns out for me, it was not the "morbid obesity" code that was my issue, it was the secondary codes that were not valid. They took out the secondary codes and then it was covered. Find out if they have secondary codes being rejected. As BCBS what the issue is specifically.