Out of Network Health Coverage for Diagnostic Medical Tests, Lab and X-Rays

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Jeffrey Johnson is a legal writer with a focus on personal injury. He has worked on personal injury and sovereign immunity litigation in addition to experience in family, estate, and criminal law. He earned a J.D. from the University of Baltimore and has worked in legal offices and non-profits in Maryland, Texas, and North Carolina. He has also earned an MFA in screenwriting from Chapman Univer...

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UPDATED: Aug 13, 2020

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You go to the doctor on your insurance carrier’s list of participating physicians for a routine physical, and he orders x-rays and lab work performed in an out of network facility. You find out that your insurance carrier approved the doctor’s visit, but the follow-up diagnostics were not covered at all under your existing policy and you unwittingly become responsible for the daunting bills. You are floored and question whether you have to ante up.

In short, if you received the health care services, you are on the hook for the bill. You have a responsibility to be proactive in your own care. YOU need to make sure your doctors know which labs participate with your health insurance plan, so they can send your tests to the right place.

And if you are going outside the doctor’s office to get the tests done, then you need to check with your insurance carrier on where you can go – do not rely on your doctor to know. You should understand that your doctor has many patients with lots of different health insurance plans. He cannot possibly be expected to know the nuances, coverage limits and networks of every plan by heart. You are only one patient, with one health insurance plan, and it is your responsibility to become familiar with every aspect of that plan, if you want to make sure your bills are paid correctly.

Too many patients assume that their plan is too complicated to understand and think their doctor will just “know”, and that is how they end up in such situations with unexpected expenses. In the future, you can avoid this by getting the list of in-network labs and diagnostic facilities from your insurance company’s web site, or ask them to mail you a catalog. This way, the next time you need a test done, you will know where to go if you want to remain in network, and you can research what portion your own provider will cover and understand your financial exposure if you go out of network.

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