Deny Claim / PCP Procudure

[steph_ww]

Does my In-network PCP responsible to inform me or get pre-authorization from Aetna before running any tests on me?  

I live in Georgia.

I got billed by some lab work which was excluded from my plan (Individual Open Access PPO) coverage.  I have filed an appeal but did not win.  Previous decision was upheld and explained that the Pap test is consider investigational and therefore not convered.  It's listed and quoted in details and I understand that part well.

My point here is that my In-Network PCP did not mention to me any coverage reagarding this test.
After receiving the Bill from the Lab, I found that my PCP didn't get any pre-authorization or didn't even check on my coverage before running test on me.  The weird thing was that they ran the Pap test on me twice.  The first time was when I visited with sore throat.  Then about a week later, they call me up to do Pap the second time because my smaple was expired when the lab try to use it to get another index.  PCP also said that the second time Pap was not urgent ("come in when i have time"), because my 1st result was not just totally normal.  So I went to the office and took the Pap for the second time about 2 weeks later.

I assumed that as In-Network PCP they are responsible for all those paper work and coverage check.  So I didn't confirm my coverage with PCP before the Pap test.  There were no paper/disclosure/waiver form for me to sign regarding the Pap.

I want to fight for this bill. The bill is $100, and it is already one thirds of my rent.
Please tell me which direction I should go to fight for it.  It felt I am mis-treated by my PCP.
Any suggestion will be appreciated.

Thank you for your time.

Stephanie

[HH5]

While understanding the authorization requirements is really your responsibility, many providers or their office staff will do some of the legwork as a courtesy to the patient.  In this case, I'm not sure you have the case for an appeal with your insurer unless you actually think they denied this incorrectly, especially since it sounds like the error was in your PCP's lab (disclaimer - I'm not a physician or lawyer, and don't have all the facts about your issue).

Your best course of action might be talking with your PCP's office.  You could ask that they reduce or even cover the $100, as you would expect that they work in partnership with you to ensure the care they are recommending is truly necessary and covered, especially in the case of 2 identical procedures in two weeks.  You may also have a case that the lab should have been able to do what they needed with just one sample.

Either way, your best course of action is approaching your PCP's office, and asking them to work with you on this as part of a long-term phsycian-patient relationship.

Find more info at http://www.healthharbor.com, and perhaps post this question on that forum.

[panda531]

you shouldn't have to pay twice.

btw, why would a PCP be doing a PAP test?  I don't know where you live. Here in N.Y, I've never heard of a PCP doing a PAP test ever.

Only a GYN Doc would do that