Health Insurance Forum - Physical & Lab Work. Only Physical Part Covered By Insur

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Q: Physical & Lab Work. Only Physical Part Covered By Insur

asked by: praveen64 on March 24th, 2007

New User

I had been to a doctor for a physical. He did the physical and found everything normal and as routine he ordered for some lab work (blood test) after the physical. The total bill was about $250 for physical and about $300 for the lab work.

However my insurance (UnitedHealthcare) paid only $250 saying this is the maximum for physical. The doctor's office sent the remaining bill of $300 to me.

Now UnitedHealthcare says they would pay for the lab work if that was not billed as 'preventive'. The doctor's office is refusing to bill lab work as non-preventive.

Note: This doctor is within the unitedhealthcare network. So its not the case where I visited an out-of-network doctor.

Can I do anything about this? Can I argue that if the doctor found everything normal in the physical, why did he order for lab work? Has anyone else been in a similar situation?

Replies(2)

GLSheridan

replied on April 28th, 2007

New User

Re: Physical & Lab Work. Only Physical Part Covered By I

You can attempt to appeal the decision, however, there is a time limit on appeals. For example, your insurance company may only accept an appeal within 180 days from the date that you visited the physician.

As far as billing, your insurance company is correct. If your policy limits preventative benefits, and those benefits are exhausted, any claims submitted with a preventative diagnosis will be denied. Your physician will need to rebill with a non-routine diagnosis.

praveen64

replied on April 28th, 2007

New User

Yes I did send an appeal to both the insurance company and the physicians office and spoke to both of them multiple times.

But end result was that physican was not ready to resubmit the claims as non-routine. And insurance company kept sticking to the fact that the plan has a $250 maximum for preventive.

Also, for the appeals I had sent written letters to both.

As a slightly offtrack issue, I also tried to ask them why was the benefit capped to $250 given that the physican was in-network. That would almost mean anybody who belongs to the plan, and goes to a physical would have to pay upto $300 out-of-pocket as typically the bill would be $550. And most people would miss to read the fine print capping a max of $250 for preventive care.

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