Doctor's Office Scheduled Exam Only If Health Insurance Would Cover It; Wasn't Covered

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Call insurance company.

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So call them and just explain the situation?

One issue is that our flex account drafts automatically. So a $157 payment already went to the bill. Think I can get that back?

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We asked her specifically if it would be covered by insurance and she said "it should be."

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Never expect the physician to have a clue about whether something is covered.

Your insurance company.

There should be a number on your card to call.

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Never expect the physician to have a clue about whether something is covered.

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This, this is nothing against your physician but they can't possibly know what everyone has coverage on. There's a lot of different options out there, some are great at knowing insurance some are terrible.

You should always consult your insurance before hand.

How much was the exam's total cost? I'm assuming it wasn't exactly $2500?

What was the test?

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Apparently y’all missed the part where the doctor’s office indicated they were going to check with the OP’s insurance provider before proceeding.

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Verbally sure. Also, its not like the OP asked the billing specialist up front and they confirmed it in writing. It sounds like the OP asked the Doc and the Doc answered leisurely.

Unfortunately that's not really something you can hold the Doc to, is all I'm saying. The Doc office may help them out here, but they may not. Ultimately its the customer's job to know what exactly they are covered for.

Call insurance and explain what happened. Sometimes they'll make a one-time exception in cases like this. Unfortunately the ultimate responsibility on knowing what is covered is on you, so the OB/GYN isn't really to blame.

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It is your responsibility to verify coverage with your insurance provider.

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If I call BCBS's 1-800 line and ask them about an ultrasound, they're going to read the same line from my EOB page that says "Covered w/ exceptions" (paraphrasing) and want the billing codes. However, those codes vary based on the provider, the MD that reviews the US, etc. This is after waiting on hold for 45 minutes, and calling the Doc office's billing department 7 times because you've left messages that they don't return because their automated system just sends you there.

So you naturally turn to the doctor's office, that knows exactly how it will be coded, and has direct access to a insurance rep, along with an online system that can provide an accurate cost for the procedure.

While correct, and technically speaking, the OP should have verified himself. The issue here lies with an individual/group the OP trusted to obtain the accurate information.

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While correct, and technically speaking, the OP should have verified himself. The issue here lies with an individual/group the OP trusted to obtain the accurate information.

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Sure I should have. But we have teacher's insurance and everything has always been covered. I've never had to double check with an insurance company to know about costs. It's always been really low, so when the doctor said they would only schedule the appointment if it was covered, I assumed it would be, you know, covered.

I can accept fault for being spoiled with health insurance and not realizing that I too can get hit with a large bill unexpectedly if I don't do my homework.

But something that influenced this too was when I had to go to "optional" PT as prescribed by my doctor. Insurance covered 80/20, and I wanted to know what my bill was going to be. The doctor's office said they didn't know what it would be because it would have to be filed as a claim and negotiated with the insurance company. They told me to call my insurance company. So I did. The insurance company told me they couldn't give me a number unless the doctor's office filed the procedure (or whatever a PT visit would be called) and they could see how much they would cover. I had both offices blatantly tell me they could not give me a number without consulting with the other office.

I left that experience thinking that it was impossible to truly know what a medical procedure would cost as it requires the two offices speaking to each other. So when our doctor said, "We'll talk to them and only schedule it if it's covered," I assumed that's all I was capable of doing.

Like you said, I would need the billing codes, but the doctor didn't give us an explanation of the procedure. She just said she thought we should have an ultrasound with a specialist to see if there were any kidney issues. If I called the insurance company and said, "We're getting an ultrasound but a special kind," I imagine they would have wanted more specifics before giving me an exact number.

I should also mention that this specialist is booked pretty far out and with my wife's work schedule, it can be hard to find a good time to book any doctor's appointments. So the doctor told us it would need to be scheduled sooner rather than later.

I don't know if I buy that it could have been as easy as "doctor gives us the name of the procedure and the cost. We phone the insurance company. They tell us the amount we would owe." The OB/GYN didn't even really know as she was sending us to a specialist. The specialist after making the appointment would have had to give us the exact names and descriptions involved in the screening. Then we'd have to call the insurance company with those exact names and have the insurance company tell us with certainty the cost of those items and how much they would or wouldn't cover.

Considering my experience with the PT, I don't think there's enough clear communication between the parties involved to ever actually find out the cost of a medical procedure.