Avoid Out-of-Pocket Costs for Labs and Tests

Labs and other tests are a common part of most doctor visits, and their purposes are rarely questioned. Patients tend to assume that any test their doctor orders must be medically necessary and, therefore, will be covered by the Health Plan. However, this is not the case.

The Health Plan covers only services that it deems medically necessary, and these include testing. Before obtaining labs or other tests, you should know the steps you can take to better understand whether they will be considered medically necessary so that you avoid having to pay out-of-pocket for expensive tests deemed not medically necessary by the Health Plan.

Use a Network Lab or Imaging Center, If Possible

Just as network providers offer savings over those outside the network, the same goes for labs and imaging centers that perform the tests your doctor might order. If you have a choice, it is recommended you always use a testing/imaging facility within the Anthem Blue Cross network, as network facilities charge discounted, contracted rates. Non-network facilities may charge what they want, which often means increased out-of-pocket costs.

Please note, however, that having a test performed at a network facility does not guarantee the test will be covered under the Health Plan. As you will read below, additional factors should also be considered.

Talk to Your Doctor

Learning the purpose of any recommended test can give you a more accurate assessment of what the Health Plan might cover and what your out-of-pocket expenses may be. The information your doctor provides can also better guide your next steps, which might include you or your doctor contacting the Health Plan to request a predetermination as discussed in the Talk to the Health Plan section. You can begin the conversation with your provider using these five questions:

1. Why are these tests being ordered?
   Although the answer to this question may seem obvious, medical providers order labs and tests for various reasons depending on your symptoms, medical conditions and circumstances. When discussing this question with your doctor, listen for terms like “investigational,” “new” or “experimental,” and obtain assurances that the tests are being ordered to specifically diagnose or treat your symptom or condition.
2. Have these tests been denied by insurance before for being investigational, experimental or not medically necessary?
   If the doctor indicates these tests have previously been denied by insurance carriers, you should contact the Health Plan to confirm whether the tests will be covered.
3. Is this test the standard of care for the treatment or diagnosis of ____(condition)?
   Standard of care is an important criterion the Health Plan uses to determine whether a test is medically necessary. The term refers to the generally accepted medical practices that health care professionals use to diagnose or treat such a condition. Asking your doctor if a test is considered the standard of care for your condition can help you better understand why the test is being recommended, where in the treatment plan it fits, and if it might increase your out-of-pocket costs if it is not the standard of care. The doctor’s response, coupled with research from credible medical sources, can confirm whether the test is commonly used to diagnose or treat your condition and can give you an idea of whether the Health Plan will deem the test medically necessary.
4. How will these labs or tests affect my overall treatment plan?
   When trying to determine whether tests or labs may be covered by the Health Plan, consider the explanation your doctor gives for how the results will be used. Seek to understand whether the results will directly determine the next steps of your treatment plan.
5. Is this a repeat test or a genetic test?
   In the case of repeated tests or genetic testing, ask your doctor to contact the Health Plan to determine coverage. Repeating tests may be a routine practice for a given provider or facility, but the Health Plan may have a limit on how often a particular test can be performed within certain time periods to be deemed medically necessary. When it comes to genetic testing, although such tests have grown in popularity, they are used for investigational or informational purposes only, which would not be considered medically necessary.

Talk to the Health Plan

After talking with your doctor and prior to the test being administered, you can request that your provider contact the Health Plan for an assessment of whether the test is considered medically necessary. This voluntary request for information is called a predetermination and can help you to estimate coverage for the services.

A predetermination is a written analysis that informs you whether the lab or test being requested is covered and, if so, to what extent. It is not a preauthorization or guarantee of coverage, but allows you to potentially avoid unexpected out-of-pocket costs later.

To start the predetermination process, your provider should submit the applicable medical records and a letter of medical necessity, including diagnoses and procedure codes for the services being considered, to the Health Plan’s Claims Department via fax at (323) 782-9287 or via email at hpclaims@dgaplans.org. After the information is reviewed by the Health Plan, you will receive a written response that determines the medical necessity of the tests. If your provider has any questions about this process, the provider should contact the Health Plan at (323) 866-2200, Ext. 401.