Defy - Insurance covering bloodwork

[johndoesmith]

Why not get your policy and read the section on blood test coverage? It should be spelled out

Oh sure, I tried that, and it contradicted itself in multiple places. When I called support to ask them about it, they denied everything in writing, would offer me nothing in writing and basically said "that's up to labcorp" and would mention nothing relating to fertility was covered.

They didn't define what fertility entailed.

Just said "that should be covered".

 

[HarryCat]

Oh sure, I tried that, and it contradicted itself in multiple places. When I called support to ask them about it, they denied everything in writing, would offer me nothing in writing and basically said "that's up to labcorp" and would mention nothing relating to fertility was covered.

They didn't define what fertility entailed.

Just said "that should be covered".

Yes, exactly, and you know there is someone at the insurance company who makes the decisions to write to software to process the claims the way they do, but he/she is in some department hidden away from the customer service reps.

 

[KarlHungus]

So does Defy only accept lab work from LabCorp? My insurance will pay 100% of out of network ordered labs as long as they are done at an in-network lab (not LabCorp).

 

[johndoesmith]

Yes, exactly, and you know there is someone at the insurance company who makes the decisions to write to software to process the claims the way they do, but he/she is in some department hidden away from the customer service reps.

Some bean counter somewhere determined what's medically necessary and what isn't.

Problem is tier 1 phone reps do not have access to that information.

They eluded to it, even mentioned that there's a list, but they're not giving it to me.

I very bluntly asked for it, with cpt codes and quests lab codes and everything.

Defy does not only accept labcorp labs. Any lab will work.

 

[AntCon]

I contacted Anthem in regards to this same issue .. The rep I spoke with looked up Defy Medical and saw them in some out of network database thing they have and said (under my plan) they would cover them
as an out of network/out of state provider.

 

[CoastWatcher]

So does Defy only accept lab work from LabCorp? My insurance will pay 100% of out of network ordered labs as long as they are done at an in-network lab (not LabCorp).

No, Defy does not require you to use LabCorp.

 

[Vince Carter]

Given I have that lab card, Quest, and Defy works with me on scripts like they have been, it's a god send in savings for me, given I'm paying nothing at all for my labs. Most of the EOBs I get on my labs are listed and total out to thousands of dollars for one set of bloodwork, certainly that is full retail and it's ridiculous.

 

[Esq]

Regarding my labs, my Anthem BCBS policy only says that "Your Plan provides Covered Services when the following services are Medically Necessary: . . . Diagnostic x-ray and laboratory procedures." "Covered Services" are in turn defined as "Medically Necessary health care services and supplies that are: (a) defined as Covered Services in the Member's Plan, (b) not excluded under such Plan, (c) not Experimental/Investigative and (d) provided in accordance with such plan." If the labs are a "Covered Service," then as a PPO plan coverage amount and which deductible is hit depends on whether the labs are in-network or out-of-network.
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Labcorp is in-network in my state, but apparently not in Florida. Quest appears to be in-network in both. One would think that would mean I could use Quest, and it would be covered in-network regardless of whether the services show as being done in Kentucky or Florida, but others have had the opposite experience.
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For me, all of this is moot unless I hit my deductible. If I don't, then I might as well just pay the Defy discounted prices which likely are close to the insurance negotiated rates. The savings come if I hit my deductible - then I'm only paying 15% from then on. This year, having had three rounds of rather expensive labs (cortisol!) run, I would have hit my deductible by now and then some had those been billed to insurance and covered as in-network. Any remaining labs for the year would be at 15%. It's just so risky unless I know in advance 100% that the labs would be considered in-network Covered Services; otherwise those labs are going to cost me 3 or 4 times the Defy rate out-of-pocket.
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Before going to law school, I spent over a year working in customer service for one of the largest health insurance companies. I can only imagine the headache for those bottom tier C/S reps to figure someting like this out - labs being done at an in-network lab, but ordered by an out-of-network provider, and for whatever reason showing as being done out-of-state even though they weren't. I doubt I would have been able to give an informed answer and I doubt kicking it up to a manager would have helped.

 

[Esq]

I just spent over an hour chatting online with Anthem about this, and the response I got from the rep I chatted with matches up 100% with what HarryCat was told. Labcorp and Quest both submit claims showing the location of lab services as where the referring physician is located (in this case, Florida) regardless of the state where the blood draw takes place.
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According to Anthem: "The referring provider is out of network and located in Florida. Even though the rendering provider is in network and is located in Kentucky, it will be filed in the state of the referring provider which is Florida. I called Florida, Quest diagnostics and LabCorp is out of network with Florida. So if you have the labs done, it will be out of network because it will be filed with the state of Florida."
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When I pointed out that the "Find A Doctor" tool on their website shows Quest in Tampa as being in-network for my plan, she didn't really have a solid response other than to say that she called Anthem in Florida and was told LabCorp and Quest are both out-of-network for my plan in Florida, and therefore it would be treated as out-of-network. She also referred to the online disclaimer that the "Find A Doctor" tool might not be accurate. It makes absolutely no sense to me, but to try to get the labs covered after-the-fact and after this chat would be a very risky move.
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Bottom line, at least for my plan (which does not specify between in-state and out-of-state benefits), Anthem would process the Defy labs as out-of-network regardless of the lab. I'll keep paying the Defy rate it looks like.

 

[HarryCat]

I just spent over an hour chatting online with Anthem about this, and the response I got from the rep I chatted with matches up 100% with what HarryCat was told. Labcorp and Quest both submit claims showing the location of lab services as where the referring physician is located (in this case, Florida) regardless of the state where the blood draw takes place.
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According to Anthem: "The referring provider is out of network and located in Florida. Even though the rendering provider is in network and is located in Kentucky, it will be filed in the state of the referring provider which is Florida. I called Florida, Quest diagnostics and LabCorp is out of network with Florida. So if you have the labs done, it will be out of network because it will be filed with the state of Florida."
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When I pointed out that the "Find A Doctor" tool on their website shows Quest in Tampa as being in-network for my plan, she didn't really have a solid response other than to say that she called Anthem in Florida and was told LabCorp and Quest are both out-of-network for my plan in Florida, and therefore it would be treated as out-of-network. She also referred to the online disclaimer that the "Find A Doctor" tool might not be accurate. It makes absolutely no sense to me, but to try to get the labs covered after-the-fact and after this chat would be a very risky move.
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Bottom line, at least for my plan (which does not specify between in-state and out-of-state benefits), Anthem would process the Defy labs as out-of-network regardless of the lab. I'll keep paying the Defy rate it looks like.

That summarizes the situation well. Thanks for that.

Just to give an idea of relative costs. For a basic follow up panel with the following tests

Testosterone, Free, Direct With Total Testosterone
estradiol, sensitive, LC/MS
DHEA-S
CBC w/diff
PSA
Prolactin
Progesterone

I was charged $725 from Quest. This was counted against my deductible, so I'd reach my deductible pretty fast doing it this way.
For the same tests from an in state provider I was quoted $310 by BCBS.
The same tests through Defy are $151

 

[AntCon]

Yea I forgot to mention in my post that I already met my out of pocket expense for Anthem

 

[stevep]

So does Defy only accept lab work from LabCorp? My insurance will pay 100% of out of network ordered labs as long as they are done at an in-network lab (not LabCorp).

Defy will accept lab work from other labs. Defy tells me what labs they require and I pass that request to my PCP who does the lap work and then my PCP faxes Defy the results.

 

[KarlHungus]

Defy will accept lab work from other labs. Defy tells me what labs they require and I pass that request to my PCP who does the lap work and then my PCP faxes Defy the results.

My PCP thinks that everything is a natural part of aging. (I know, I need to find a new PCP) Going to see a TRT Dr. here soon (In-network, just makes things simpler for insurance). If he sounds like a stooge, the next stop will be Defy.

 

[stevep]

My PCP thinks that everything is a natural part of aging. (I know, I need to find a new PCP) Going to see a TRT Dr. here soon (In-network, just makes things simpler for insurance). If he sounds like a stooge, the next stop will be Defy.

He's right to a point, but that doesn't mean you have to accept feeling like crap. If he doesn't think quality of life is a priority for his patients then you're on the right track by moving on to Defy or another provider that will work with you.