Michelle's doctor suggested she get a bone marrow biopsy. The procedure, performed by a provider in her network, lasted only a few minutes. She felt relieved. Then her insurer refused to pay for the genetic analysis — leaving her with a $2,400 bill.
In a fast-evolving field with lots of money at stake, tests that a doctor or lab may regard as state-of-the-art an insurer might view as experimental.
Tests"can be performed a number of different ways by a number of different laboratories who charge different amounts," Nichols said. "Different providers have contracts with different diagnostic companies," which can affect a patient's out-of-pocket costs, Nichols said."It is incredibly complex and really difficult to determine the best, least expensive path."
An agent for her insurer told her that her doctor hadn't gotten preauthorization for the testing. But in an email to Kuppersmith, a Genoptix employee told her the insurance company had denied the claim because molecular profiling was viewed as experimental. Benjamin said that's not OK, explaining:"I think a one-year-old, vague form like the one she signed would not comply with the state law — and certainly not the spirit of it."
Patients should ask their health care providers if any outside contractors will be involved in their care, including pathologists, anesthesiologists, clinical labs or radiologists, experts said. And check if those involved are in-network.
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