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This is a test for me. I'm used to using the software side of StackExchange, but I think this format could work for this. Let's see and please let me know if there's a better place to discuss these things.

This is very specific to United States. I'm basically trying to protect myself from the healthcare system.

I recently went to the doctor for preventive care. The doctor asked for a few lab exams and they told me they thought the insurance would cover 100% but they weren't sure and that I should verify with the lab beforehand.

When I got to the lab they said they didn't do billing and so for the next 10 days I was going in and out of the lab, hospital and on the phone with the insurance company.

The main issue was that the Procedure Codes (PCTs) that the hospital gave me and the ones the insurance wanted were different and nobody knew what to do.

In the end I learned that I needed Diagnosis Codes (Z codes) for each procedure ( in the format Z11.59), Hospital specific codes (C010010234) and billing codes (5 digits like 81800). The codes are not accurate, but they look like this. I also have the impression that the Z Codes and the Billing codes are the important ones.

I got a lot of angry people yelling at me that the insurance would cover and the insurance telling me that they couldn't verify without all the codes. I only got the billing codes (the biggest challenge to get) because a Lab Technician was savvy enough to explain to the Hospital reception where to find the information, before that even the billing office told me they had no clue what I was talking about.

Apparently it is very unusual for people to want to know if the insurance will pay for something in advance.

For next year I am going knowing that I need to make sure I get all these codes while I'm still in the doctor's office and make a call to the insurance right away before I leave the restricted area to be able to avoid such an ordeal. Once you go out the door there's no going back and it's almost impossible to reach the doctor.

My experience was horrible for everyone involved but I was surprised that I actually got a straight answer in the end. I had to get 10 different codes and I think at least 7 of them were essencial for the insurance to guarantee that they would cover. Since these were 100% covered because they are preventive care I didn't get much inside in how to figure out prices, but it might be possible if you know where to look and what to ask.

Which brings me to the heart of the question: if I could get an answer by following the right protocols, would something like that be possible to also learn the price of a procedure if I know where to look and am in a position to be diligent while seeking care for myself or someone else in my family?

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    Are you new to the US healthcare system?
    – littleadv
    Dec 22, 2023 at 7:09
  • Relatively new, battle scarred
    – A Campos
    Dec 22, 2023 at 11:29
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    My experience is that being proactive is pointless, but engaging your employer's benefits department if something isn't working out as it should can help quite a bit, especially if its a large employer. Don't stress about it, it's a game that the doctors and the insurance here are used to playing.
    – littleadv
    Dec 22, 2023 at 19:17

1 Answer 1

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When determining the relevant monetary impact for you related to a particular medical procedure, you do need the code for the test being performed and the reason why the test is being performed.

Once you know those things the insurance company can determine what your out of pocket expenses will be. This is tricky if the some of the procedures are not being performed by the doctors office, because you have to contact multiple companies. The primary care physicians office will not have any idea what labx charges for that test.

When getting an estimate your goal is to get the out of pocket cost. This is specific to the test, the reason, and where you are in the deductible/coinsurance timeline. The doctors office generally doesn't have detailed information about your insurance situation.

Adding to the complexity of the process what the doctor/provider charges may be above the negotiated rate they will actually get based on your insurance. A procedure that they will bill $200, may have a negotiated rate of $120. That lower number is then what the insurance company uses to determine what your out of pocket expenses are. If you are responsible for 20% it will be 20% of $120, not 20% of $200.

Getting this information is difficult. Tracking down the codes takes time. There is always a risk that the estimate is bad, if the code you are given doesn't match what they will eventually bill when the procedure is done.

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