Labs or imaging not covered
Because each patient's policy is different in terms of what their insurance considers medically necessary or not there may be variations in how each patient's lab tests are covered. Some patients may have a lab test that is ordered by the doctor that is only covered under a medical diagnosis versus a screening diagnosis. Other patients may have coverage for the same lab under either diagnosis while yet other patients may not have any coverage under any diagnosis because their insurance does not consider the test to be medically necessary under any situation and they will not cover it at all.
Because of these variations in individual policies we always recommend and instruct patients that they are responsible for calling their insurance to ensure that they are advised of their coverage PRIOR to getting any orders including labs and or imaging completed. These instructions can be found in our financial policies, on patient care summaries issued after the visit and on the visit check out form so that patients are reminded in multiple areas of the importance of contacting their insurance before completing orders to ensure that they are appropriately advised of their financial responsibilities for each test.
Since we are not the billing entity (i.e. the facility completing the lab or imaging test) we are unable to provide the direct CPT codes for each test however we do provide the test codes for each test on the lab orders to our patients so that they may contact the lab directly in case their insurance requires the CPT code to verify coverage. We also advise patients that they are responsible for contacting the lab BEFORE they get any orders completed to ensure that the orders that have been recommended by the doctor are covered under your assigned diagnosis to ensure that the patient is covered for that test as our office DOES NOT adjust diagnosis codes after tests have been completed.
If you contact your insurance company and they advise you that a test that the doctor has ordered is not covered under your policy BEFORE you have completed the test then the doctor may still be able to adjust your diagnosis to one that may be covered under your policy depending on your individual medical record. Our office is not able to add a diagnosis that is not supported by the medical record . If you contact us PRIOR to having the lab completed and there is no other medical diagnosis that will be applicable to the test that was ordered then our office will be able to advise you as to alternatives to complete testing. We do also try to work with our patients and keep a roster of facilities that we can refer patients to that typically have more affordable testing costs for testing that is not covered by your insurance and payment plans for patients that may have high deductibles for services like labs or imaging.
If you do not follow the office recommendations and contact your insurance company BEFORE having your orders completed and after the fact you receive an unexpected bill from the lab you may be advised that your orders are not covered unless they are ordered under a specific diagnosis. If you find out that your orders needed a different diagnosis when you contact your insurance after the fact our office policies do not allow us to adjust the diagnosis on orders that have already been completed. This is why we advise our patients multiple times to contact their insurance before getting any lab orders or imaging orders completed. In this type of situation if our office has not been contacted BEFORE you completed the test to see if another diagnosis was applicable then the patient would have to work out a payment arrangement directly with the lab as we do not get involved in any billing issues between an external site such as a lab or imaging facility and your insurance company since we are not the billing entity and we did not provide those services. We can only do our due diligence to make sure that our patients are advised of the precautions that they should watch out for before engaging in completion of any orders for services that we do not provide so that they do not receive any unexpected financial responsibilities.