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Question: Need SD Approach to Negotiating Reductions to Unexpected Med Bill

66 30 February 10, 2018 at 11:04 AM in Finance
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ConfusedMy wife & I got assigned a new HMO doctor recently. The doc prescribed the Cologuard test for both of us. Cologuard is the first stool DNA colorectal cancer (CRC) screening test. If you care to read about this test for background and pricing, please google these keywords:

Cologuard cost

These tests are fairly new and expensive. My wife's unpaid bill is $649 after the HMO declined to pay it, because it wasn't pre-approved. In my wife's case, I think I can get Medicare Part B to pay for it (I believe I read that Medicare will pay approximately $500 for reimbursement). Unfortunately, I don't have Medicare so I will have to eat the cost. I CAN afford to pay, but would prefer to develop a negotiation strategy to reduce my out of pocket expense.

I have done some web based research on this topic. Most of the info I found is fairly generic such as "never pay retail". "Med providers negotiate every day". "Don't try to negotiate with the first person that answers the phone in the medical billing department", etc..

Would appreciate any advice and, or assistance the SD community can provide. Also, if you have any good links to other forums that may assist, please post this info.

Thanks in advance!

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HMO is called Global Health. Not a national wide operation. Only in state of Ok.

Thanks!
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What is your income? I think if your income is low enough you can get it free (depending on your state)
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Unfortunately I CAN afford to pay. I just don't want to pay full price. Also, found out I can request a "Reactive Prior Authorization" from insurer, but I doubt they will approve it. Although I might try.

Was hoping to get an insider familiar with this topic to offer some negotiation tactics. For instance, would it help to get doctor's insurance folks to contact the test provider and request a discount on my behalf to Medicare rate? Normally, my doctors have told me (in the past) whether or not my insurance would cover a procedure. In this case, they did not (ultimately payment is my responsibility). On the other hand, the doc's office may have some leverage since the provider wants to doc to continue recommending their procedure. POSSIBLY A NEGOTIATION LEVERAGE POINT.

Also, I found out that during my research that new laws have made it harder for med providers to report you to credit agencies. This may give me some leverage if I simply drag my feet in paying the provider. Here is the article.

http://time.com/money/4943931/new...t-reports/

Lastly, the dilemma I have found may self in apparently effects many. I will post my findings here to help others.

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Quote from PaCuLard
:
Unfortunately I CAN afford to pay. I just don't want to pay full price. Also, found out I can request a "Reactive Prior Authorization" from insurer, but I doubt they will approve it. Although I might try.

Was hoping to get an insider familiar with this topic to offer some negotiation tactics. For instance, would it help to get doctor's insurance folks to contact the test provider and request a discount on my behalf to Medicare rate? Normally, my doctors have told me (in the past) whether or not my insurance would cover a procedure. In this case, they did not (ultimately payment is my responsibility). On the other hand, the doc's office may have some leverage since the provider wants to doc to continue recommending their procedure. POSSIBLY A NEGOTIATION LEVERAGE POINT.

Also, I found out that during my research that new laws have made it harder for med providers to report you to credit agencies. This may give me some leverage if I simply drag my feet in paying the provider. Here is the article.

http://time.com/money/4943931/new...t-reports/

Lastly, the dilemma I have found may self in apparently effects many. I will post my findings here to help others.
I'm guessing SD readers on average are less than 50.

Cologuard doesn't seem like an emergency? Why not find out cost/negotiate up front? (hindsight is 20/20)

If you don't care about credit score maybe just don't pay it? Let it go to collections & then negotiate it down. More brainstorming. I would google negotiating medical bills.
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#7
Most* medical providers are OK as long as you are making some kind of payment on a somewhat regular basis. If your only goal is to spread out the payments to keep from blowing your budget one month, just call and ask for a payment plan. Or, just send payment for 1/4, 1/6, 1/3, etc of the bill; as long as a payment is made, the system may just keep generating an invoice each month with no problems.

Definitely check into the prior authorization form, as you have nothing to lose.

Beyond that, just keep calling. Offer to pay the whole bill right then and there for a discount. Call again. Be prepared for it to drag on for months and months. Call some more. I've heard that the end of the year is a better time for getting discounts, as providers want to close the books, but haven't had any luck with that myself.

It should go without saying that when you do call, always be polite, calm, and courteous.


*most, some, many, all, none, a few, YMMV.
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Marshall: Have the rest of you guys figured out by now that mmathis is the smartest guy on SlickDeals?
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What kind of backyard HMO is this?

For one, a real HMO do their own test. 2nd, something new and unproven like this wouldn't be prescribed by a HMI doctor. 3rd, didn't the doctor discuss cost if this isn't a HMI sanctioned test?
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A little more background: Yes I unknowingly made several key "assumption" mistakes that got me in this situation. Unfortunately, I did not realize I was making these assumptions at the time. Hopefully my lessons learned will help others.

More Background: The new doc simply said that this test was somewhere in-between (i) a colonoscopy (Yuk) and (ii) poop on a stick wipe on card method (Reliability question). My insurance paid for a full colonoscopy a few years ago and it is too early for insurance to pay for another one. However, I previously had a polyp and believe my risk is higher than the general population.

Key Wrong Assumptions:

(1) Assumption 1. I assumed that this test was automatically covered by insurance like the "Poop on the Stick" method since it was not a colonoscopy.

(2) Assumption 2. I knew that I was ultimately financially responsible for the payment of the test, but was lulled into relying on the doc's insurance folks to research and advise as to whether or not a procedure was insurance reimbursable. This has always been the case in the past.

Anyway, hopefully my experience will help others. Will post ongoing results.

Thanks!

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Quote from PaCuLard
:
A little more background: Yes I unknowingly made several key "assumption" mistakes that got me in this situation. Unfortunately, I did not realize I was making these assumptions at the time. Hopefully my lessons learned will help others.

More Background: The new doc simply said that this test was somewhere in-between (i) a colonoscopy (Yuk) and (ii) poop on a stick wipe on card method (Reliability question). My insurance paid for a full colonoscopy a few years ago and it is too early for insurance to pay for another one. However, I previously had a polyp and believe my risk is higher than the general population.

Key Wrong Assumptions:

(1) Assumption 1. I assumed that this test was automatically covered by insurance like the "Poop on the Stick" method since it was not a colonoscopy.

(2) Assumption 2. I knew that I was ultimately financially responsible for the payment of the test, but was lulled into relying on the doc's insurance folks to research and advise as to whether or not a procedure was insurance reimbursable. This has always been the case in the past.

Anyway, hopefully my experience will help others. Will post ongoing results.

Thanks!
The way it works with my insurance is that it gets approved or denied before we get the go ahead or not to do a test. We don't do a test first and hope it gets approved. The doctor forwards the request to the insurance company and then let's us know if it's a go.
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Quote from ghostofposterspast
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The way it works with my insurance is that it gets approved or denied before we get the go ahead or not to do a test. We don't do a test first and hope it gets approved. The doctor forwards the request to the insurance company and then let's us know if it's a go.
IT really depends on the type of insurance. Some insurances require referrals for the most basic of things, IMHO just to use an excuse to not cover something, meaning the referral is easy to get and they'll approve it, but don't get one and you're screwed. Other times preapprovals are more used to get an idea of what it will cost you OOP. I've done that many times with our dentist. Now, being more of an elective area of medicine, consumers are much more cost-conscious so asking the office to do a preapproval isn't a thing, and many times they will just go ahead and do it without being asked.
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Quote from Dr. J
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IT really depends on the type of insurance. Some insurances require referrals for the most basic of things, IMHO just to use an excuse to not cover something, meaning the referral is easy to get and they'll approve it, but don't get one and you're screwed. Other times preapprovals are more used to get an idea of what it will cost you OOP. I've done that many times with our dentist. Now, being more of an elective area of medicine, consumers are much more cost-conscious so asking the office to do a preapproval isn't a thing, and many times they will just go ahead and do it without being asked.
With my insurance company it's just a rubber stamp. I have never had anything not approved.
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Bingo! Dodged a bullet. Your advice helped!

I did some additional informal research/investigation and my HMO would have most likely denied it. Rules are fairly clear on asking for the after the fact approval. Unless it is a time sensitive emergency (life threatening) they won't approve it.

However, I called the Test Provider in a non-threatening manner. He advised me that the poop sample I submitted had a 72 hour shelf life and the DNA expired. Voila! Off the hook.

Learn from my lesson: You have to protect yourself in these manners and absolutely get every thing pre-approved on an HMO. Make no assumption.

Thanks to all the posters!
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Quote from PaCuLard
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Bingo! Dodged a bullet. Your advice helped!

I did some additional informal research/investigation and my HMO would have most likely denied it. Rules are fairly clear on asking for the after the fact approval. Unless it is a time sensitive emergency (life threatening) they won't approve it.

However, I called the Test Provider in a non-threatening manner. He advised me that the poop sample I submitted had a 72 hour shelf life and the DNA expired. Voila! Off the hook.

Learn from my lesson: You have to protect yourself in these manners and absolutely get every thing pre-approved on an HMO. Make no assumption.

Thanks to all the posters!
Lesson learned let your poop expire.
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Nuther ​Learn from my lesson:

In the end, POOP HAPPENS!!
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