A physician recommended that Edward Fernandez of Stone Mountain get a hepatitis C test during his annual physical last year.
Up to 75 percent of Americans with hepatitis C – a disease caused by a virus that infects the liver – don’t know they have it, the CDC says. And Fernandez says his doctor pointed out that the CDC recommends the test for baby boomers, who comprise the majority of cases of the disease.
Fernandez was in the target age bracket, so he agreed to have the test. It turned out he did not have hepatitis C.
A few weeks later, he received a bill from a lab company for $157.67 – chiefly, he says, for the hepatitis C test, which was not covered by his insurance.
The charge astonished him. A retired federal employee, Fernandez, now 60, says he has excellent insurance coverage, and points to the CDC’s recommendation for the test.
Fernandez considered the charge unfair. He fought it for more than a year, and though the test was finally covered this week, there were plenty of problems along the way. Last month, for instance, his account was turned over to a collection agency.
Many consumers like Fernandez wage protracted and frustrating fights with health plans or medical providers over charges.
Group health plans deny the claims of almost 2 million plan members each year, said Timothy Jost, a health law expert at Washington and Lee University School of Law, in his post in the journal Health Affairs this year.
Jost noted that a patient’s right to an external third-party review of an insurance denial is one of the health reform law’s most important consumer protections. Federal officials have delayed implementation of a state’s external review requirements until 2016.
Even with this guarantee, though, the Affordable Care Act won’t eliminate the tugs-of-war between patients and health plans/insurers or medical providers. Consumers are urged to keep a paper trail in case they want to appeal a decision.
Fighting to make a point
“The biggest mistake patients can make is avoiding their medical bills,’’ says Erin Moaratty, chief of mission delivery at the Virginia-based Patient Advocate Foundation. “It is very important to deal with any problematic or confusing bills in a prompt manner. If something feels even slightly out-of-whack in your bill, it is worthy of investigating.’’
“You’ll want to be prepared as possible with all the documentation you have handy when you get on the phone, keeping in mind that in order to ‘solve’ the situation you may need to make numerous calls to the parties involved,’’ she says.
During his yearlong fight, Fernandez contacted both the health plan and the lab company several times. The physician’s office sent letters on his behalf.
The Fernandez dispute hints at what an insurance industry official says is increasing tension between health plans and lab companies over testing charges.
The federal APWU Health Plan, after being contacted by GHN, said this week that after reviewing the claim, it would cover the test for Fernandez. Health plan officials said the original coding of the test was in error.
The health plan does not cover a Hepatitis C test as part of a routine screening test, but coverage is approved if it’s billed with a diagnosis code related to the test, Wendy Abraham, a utilization analyst with APWU Health Plan, said Wednesday.
The lab company, Quest Diagnostics, told GHN earlier this week that insured patients should contact their health plan about their coverage prior to testing.
“Generally, the relationship between the payer and the patient would be handled between the payer and the patient,’’ said Wendy Bost, a spokeswoman for Quest Diagnostics.
Fernandez had heard about the coding problem before. He says the health plan initially told him it didn’t cover the test, and after he challenged that assertion, a company representative cited the way the physician coded the test.
He contacted the doctor’s office, which then coded it differently, Fernandez says. But that was a much more general code, and didn’t help, he says.
And he kept getting invoices.
“I became caught in the middle between my physician and the insurance company and the lab,’’ Fernandez says. “It got me really upset.’’
Fernandez says he could have afforded to pay the money and skip the hassles, but “the principle” of the thing kept him waging his long fight. It didn’t make sense, he says, that his insurance wouldn’t pay for preventive care.
He sometimes got what seemed like the runaround. He says one health plan representative told him that it had no evidence the CDC recommended a hepatitis C test. In response, Fernandez faxed the health plan the CDC website recommendation, which says that “testing all baby boomers properly is critical to stem the increasing toll of death and disease from hepatitis C in this nation.’’
“I really had to prove it was true,’’ Fernandez says.
Aggressive collections are common
Though he’s not in a position to comment on this particular dispute, Graham Thompson, executive director of the Georgia Association of Health Plans, says insurers have seen a sharp increase in lab testing costs. “Some of these tests are incredibly expensive,’’ Thompson says. He adds that lab companies “are very aggressive’’ in their collection methods.
Last month, Quest Diagnostics sent Fernandez a notice that he was being turned over to collections.
Quest Diagnostics’ Bost declined comment on the company’s collection processes.
“We provide many options to help the patients get the testing they need,’’ she said.
Fernandez contacted the state insurance commissioner’s office and eventually filed a complaint there, too. The insurance commissioner’s office asked him whether he had exhausted all of his internal appeals.
“They were polite,’’ he says. “They haven’t really given me any guidance.’’
Meanwhile, he received a 60-day reprieve from the collection process.
Fernandez was gratified to hear of the health plan’s decision to cover the test. He felt vindicated.
He says there always appears to be an obstacle in the way of getting an insurer to cover a procedure or treatment. “It makes me wonder how many times they do this to people.’’
“It wasn’t just about me,’’ Fernandez says. “The longer the process lasted, it made me really wonder how many people just go ahead and pay for it.’’
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