2nd Trimester

insurance coverage for lab/screening

Just wondering if anyone's insurance didn't cover the labwork for genetic screening? I have pretty good insurance and was surprised when I got a bill from my clinic b/c the claim had been denied. Now I am bracing myself for the next bill of the 2 part screening- Everyone I know gets this labwork done when they are pregnant so I assumed it was covered- guess I shouldn't make assumptions. Did anyone else have it come back denied?

Re: insurance coverage for lab/screening

  • I am not for sure of your insurance or the specific circumstances, but I have worked in a doctor's office doing insurance claims. Claims come back denied for all kinds of reasons and they can be sent back and sometimes be reconsidered and paid. If you think it should have been paid I would definitely call your insurance and see if they will reconsider the claim. 
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  •  I would definitely call and check on that.  It's possible that someone incorrectly denied it.  I've never heard of it being denied if it's warranted by the doctor, and that's a pretty routine check...
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  • There have been so many changes with the way paper work is processed for insurance since the new health care laws it simply may be the codes that they used.

    Call the insurance company and ask them a million questions along with why it wasn't covered when it's a standard procedure. After they explain it to you call the doctors office and ask for all of the codes that it was submitted under, etc. Get a clear understanding. It's difficult when the doctors offices and the insurance just give you the run around.

    I'm going through something similar for something standard pre pregnancy and it's been almost a year and I'm finally getting somewhere. I paid the bill so it won't affect my credit but it's a pain and I call and check up on once a week.

    When you call any place take notes in a notebook and write the following, Date, Time, Person you spoke to (or employee code), extension if they have one and repeat the conversation at you're writing and let them know you're taking notes. If it's covered you're being taken advantage of. When the insurance company covers a procedure the hospital has a cap (agreement) on what they can charge (it's the cost of using that insurance co for the hospital) and sometimes the hospital/lab knows that they'll get more money if they process it as something covered.

    It's unethical and robbery when you're paying $100+ a month for insurance premiums. 

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  • i would call and ask why it was denied, and then ask them to send you their booklet of information stating everything they cover (unless you already have that saved somewhere). prior to our first appointment, i looked through my book on what they cover, retyped it out in microsoft word breaking it down by trimesters, and i bring it to every appointment because i dont want to pay a crapton of money for something that isn't covered. it's worked out wonderfully. at our first appointment i showed my doctor the tests they cover, so she knew what to do (it was all of them anyway, but i had no idea at the time). 
  • As far as I know all of my lab work and ultrasounds have been covered by insurance so far. However we chose not to have any of the genetic screening done as they have a lot of false positives and we would not change anything regardless of the out come of these tests.

     

  • i paid 468$ for the genetic lab work ...and that was not because the insurance denied it.... i had to pay it coz they applied it to my yearly deductible which is 600$....had i known i would have to pay so much i would have refused that test 
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  • oh! sorry! i just re-read your OP and saw you said for genetic screening. my insurance is really good too ($250 deductable, no co-pays, and they cover 90%) and they only cover genetic screening/testing stuff if i'm over 35 (i'm 27), so yours might do something similar. 
  • Make sure to call your insurance to make sure they cover the proper maternity. The day I found out I was pregnant I called my insurance and found out they do not cover any of the lab/ultrasounds - actually they cover nothing. My husband and I are paying out of pocket because of my insurance. You can also set up payment plans through your clinic and hospital. That's what we are doing.. 

     

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  • Mine have been covered at 100% not even hitting my deductible because they are considered preventative basic care (I have a PPO). I did check my specific policy language looking for exclusions just in case. I think if the insurance booklet does not specifically state they won't cover genetic tests, then you have a good argument that they should be covered.

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  • Good question!!!  I have an HMO and a new insurance this year: Humana.  I'm a medical biller and I know from processing what a pain in the butt they are.  You can have your referrals and they could still deny your claims.  I'm going to arm myself by keeping close watch of my claims on line and appealing any denials as soon as possible.  I may take it a step further and ask for my own medical records to back up my appeals should they deny payment.  The truth is we can't rely on the doctor's offices to do all the appeals.  If claims deny, typical procedure is to put the claims to patient responsibility to prompt the patient to call their insurance and hopefully handle it themselves.  There's just not enough staff out there to appeal every denied claim.  Coverage is a big concern for me.  I was already told the MATERNI1 test is not covered by insurance.  It could be because it is so new.  So my worries are geared toward the inconclusive CVS I had and the Amnio I'm having on Monday. 
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  • I don't actually know whether or not my insurance company will cover the tests.  My healthcare network is very slow about billing and my insurance company is slow about paying, so I haven't received any bills/statements for this calendar year yet.  The genetic counselor who talked to me indicated that the insurance company was scrutinizing genetic testing claims, so sometimes claimed were being denied because the general, instead of the specific, medical codes were being used.  She even said that if we did IVF that the insurance company, which doesn't pay for infertility treatments, would cover PGD.   When I had my D&C last year, the genetic testing on the fetus was initially denied. I didn't even have time to contact the insurance company or the hospital before it was resubmitted and paid.  I assume there was a medical coding problem that was fixed.
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  • I was told up front that it is unlikely for genetic screening to be covered by most insurance companies.  Even after tracking down the billing codes I couldn't get CIGNA to tell me how much it would cost me.  To my surprise, I just received a $1400 bill just for the ultrasound portion of my NT scan, and I still have yet to do the rest of the remaining labatory work.  I guess the good thing is is that it all goes towards my $4000 out of pocket maximum in which I am bound to meet anyway.  :/


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  • Sometimes insurance will only cover those tests if there is a reason like over 35 or genetic history of something specific.  With my last pregnancy, some of the lab work was initially denied so my doctors office had to send it back with the specific reasoning for ordering the test.  After that it was covered completely.  If insurance didn't cover it, I would have had to pay $495 for just a part of it.
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  • image ARIES326:
    Good question!!!  I have an HMO and a new insurance this year: Humana.

    Coverage is a big concern for me.  I was already told the MATERNI1 test is not covered by insurance.  It could be because it is so new.  So my worries are geared toward the inconclusive CVS I had and the Amnio I'm having on Monday. 

    Not exactly true-- If you have a PPO rather than an HMO, MaterniT21 is charged at $235  directly by the company, Sequenom. The company then tries to recoup the cost with the insurance co. Even if they are unsuccessful, they won't come back asking for more money. The company offering the test will not offer the same deal with an HMO. THey have some kind of compassionate pay plan, but it still may cost close to 2k OOP. I am glad I have a PPO for reasons like this.


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  • Also, don't confuse your deductible that you have to reach first for paying so much out of pocket. Each insurance is different. I have Cigna as well but all preventative testing is covered 90-100% and the 10% I have to pay goes toward my yearly deductible. Items that are not covered at all that I pay is also applied toward my yearly deductible as well but they aren't covered because of the plan.

    Coding is something in and of itself and it's annoying when talking to the billing departments at each hospital of people that aren't sure and just stick in a code, etc. Then they leave the responsibility up to you (the patient) to call around and figure out THEIR error.

    I like the idea of what the girl had to say earlier about listing out each item covered. I am going to do that this week.

    Last I checked genetic testing is preventative, because then the health care costs for a child you were unaware had a genetic defect is more costly than the preventative test.

    I'd totally fight it.!

     

    Good luck and go get 'em. 

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