Anyone under the age of 30 qualifies for a “catastrophic-only” plan on the Federal exchange or any of the state exchanges. That means that the insured is covered for high-cost incidents like hospitalization, cancer treatment, etc. they pay out of pocket for routine doctor visits and lab tests – but they pay at the insurance company’s contracted price. These plans are low-cost. I think they are a great idea. I wish people of any age had the option of catastrophic-only plans. In my opinion, that is the purpose of insurance – to protect you from life-altering expenses, not to cover routine visits that wouldn’t cause you to have to cash out all your savings.
The concept of preventative care being covered is to avoid the catastrophic events. Ounce of prevention much cheaper than pound of cure. But if not covered, many people just won’t do the preventive care.
I think this gives a nice explanation of why some “preventive cares” are not covered at 100%. https://www.compassphs.com/blog/health-navigation/preventive-care-covered-at-100-percent-but-what-is-considered-preventive/
Fortunately I never have a problem for myself, but I never thought I should have asked my doctor what blood tests she ordered and that I should call the insurance to make sure the tests are covered before proceeding with the tests. But reading the article and the experience with my DD’s doctor, it is probably what should have done.
Maybe if he suspected anemia or something related, if he was to add another diagnosis code it might be partially covered .
One of my kids is in professional school…and NO school based insurance is offered. We wish there was a school plan because it would be far less costly (well…the plan they had the year before she started was less costly than her individual plan).
My kid’s primary care doctor recommended a repeat echo because of a murmur that has already been cleared as no issue by three cardiologists. Kid did it. Bill was $650. We paid.
I get that. But in people under age 30, preventive care is not cost-effective on a population basis. That’s why the catastrophic-only plans are available only to this age group.
If everyone of every age had the option of catastrophic plans, then catastrophic plans wouldn’t be any cheaper than Bronze plans. Catastrophic plans are cheaper because they only enroll young mostly healthy people and don’t have to do any risk adjustment with all the other plans.
talked to the billing department today to ask why it was reasonable and necessary for the blood test for DD.
“Well, we did not know her insurance company does not cover” but that is irrelevant, right?
“When a patient comes in for a routine check up, she will need routine blood test”
I asked "when her sister went in for a annual (routine) check up two weeks later in the same office but with a different doctor, there was no routine blood test’.
The answer - then her sister did not have routine check up…
Certain types of preventative care are cost effective for under-30s. Flu shots, for example.
went to the doctor’s office, according to them the reason for the blood work is to establish a baseline, and a baseline is preventive care. I am no medical professional, but I can’t see how a baseline is a preventive care.
@annamom — perhaps you need a different MD office where they don’t order uncovered blood tests without telling patient and family who will be paying the extra?
The billing office might be able to tell a patient if their blood work will or won’t be covered by their insurance…but in my experience…the doctors don’t have this insurance knowledge. There are tons of different insurance plans and the docs just can’t possibly know what YOURS will or won’t cover.
In addition, some doctors farm out their billing.
I don’t think many doctors would be able to tell a patient what that patients insurance would cover…or not…without actually seeing the plan coverage.
If several of their patients have complained about the bill because the tests weren’t covered, that would tip the office off. The OP does state that the other MDs in the clinic don’t order the blood tests that caused these extra charges.
I think MDs and their offices get a sense pretty quickly about items that are
NOT generally covered.
Try to negotiate a discount before paying bill, which unfortunately you will have to.
Personally I don’t consider those two tests a normal standard of care for a routine checkup of a young person. You could do some googling to substantiate that before talking to them further. Depending on her age, check pediatrician association recommendations, association of family practitioners, and https://www.uspreventiveservicestaskforce.org/Page/Name/recommendations
All my life and all our kids lives, we were never given any surprise blood tests that we ended up with a huge 3 figure bill for. Our kids and H and I have some chronic health conditions and have gotten many, many blood and other tests over the years and many different places—in our state and in several other states.
I agree that it makes sense to negotiate the price of these tests and I’d ask why they were ordered any why you weren’t warned about the estimated out of pocket cost, especially as your child wasn’t complaining of any particular symptoms.
OP here. I know I will have to pay the blood work eventually, but I will let them know I am disgusted with doctor’s treatment of a young adult as a cash cow (their argument that a routine checkup would need a routine blood work, therefore, my other daughter. who went to see their regular doctor in the same office for an annual, is not considered to have a routine checkup because the regular doctor did not order any blood test is unbelievable). I also felt somehow responsible. We have been talking about find her a new doctor this office is a pediatric office. But DD has summer job and the office is 5 minutes from home, hence I made the appointment for her instead of getting her a new doctor.
Thanks for the suggestion on looking for pediatrician association recommendations, when I discussed with them today, I showed them the preventive care from different insurance companies, the government website, their own website, none suggested a baseline blood test as a preventive care, but they did not want anything to do with those information. They claimed that the doctor felt that it was necessary to get a baseline and the doctor has to order the blood work to find out whether there is any problem, hence it is preventive care. I do not think their argument is right as it could mean that they order any test in the sky with the pretense of finding something, it just does not seem right.
I will be contacting another department.
As far as what they know about insurance coverage, I think some MDs have an idea, for example, my own doctor will sometimes show me names of vaccine and told me that the insurance will likely not cover and suggest me to check. I don’t think DD is the first person to have the blood tests denied, but I believe most people will just pay. Hopefully, I can bring to their attention that they should make sure families aware of the cost.
You ARE providing a service to other patients by voicing your displeasure at how this was handled.
I can’t recall any of us ever having the tests your D was given and our kids were having A LOT of low stamina issues. Even if your D is a young adult and not a child, that’s no reason for the office to order unneeded tests not covered by insurance. You should NOT feel at all guilty. It’s challenging finding doctors for our young adults.
Very little is considered preventative care under the ACA. Its how the law was written. There is no way around that. You have to know what is covered and what is not covered. A CBC may show you slightly anemic which would be covered but iron tests which really are needed to verify anemia are not considered under the minimal plans until you reach your deductible. Also, keep in mind that there may have been a submission error which could cause the insurer to deny the claim and it happens all the time. However, many plans require you to meet the deductible before it starts paying for lab work. Call the insurer and they will tell you.
Just a reminder…in most cases blood work is done at a lab. The LAB gets payment for these services, not your doctor. It’s absurd to say the doctor is using someone as a cash cow if the doctor isn’t going to see a nickel of what you pay to the lab.
Did your doctor do this blood work?
^^it is part of the same medical group. They include labs, x-rays etc.
I do not know how the fee structure work, but I have been avoiding this doctor. In the past few years, we occasionally had to see her when the kids got sick, and their regular doctor had no availability and she always had time (you wonder why). She almost always sent the kids to testing. At the end of the session, I felt that she mentally went through a list to see where to send them to (it might be for the right reason, but I did not feel comfortable) On the contrary, the kids’ regular doctor almost never sent the kids anywhere and sometimes even no medication for similar kind of issues. When the doctor’s portion of the bill came in, there was always more line items, but as it was less than $100, I would just pay. Their office also had a nurse whom I also avoid, as anything we said, she would suggest us go to their medical group’s specialist. It came to a point that I do not feel comfortable with the two people. We do not change doctor as the kids began seeing their regular doctor when they were babies and when the regular doctor did not belong to any group (as I recall).
My own doctor belongs to a different health group, but she never pushed me to her health group’s facilities.
@scubadive I have no problem if the doctor suspected anything, but she didn’t. She claimed that she wanted a baseline, but baseline for what? One explanation was that they want to use the blood work to find out whether there is any problem, therefore does it mean that they can just do anything under the sun in order to find out problem when there was no report of anything to begin with.