Patient Advocacy: Healthcare on your Side

Patient Advocacy: Healthcare on your side

   by Martine G. Brousse, 

Healthcare Specialist, Patient Advocate, Certified Mediator

ADVIMEDPRO

Tips on Five Common Labs 

As a Patient Advocate, I often encounter bills and statements showing commonplace labs performed in various settings (office, outpatient, inpatient). I keep getting surprised, and often outraged, by the differential in pricing for those simple tests.

Patients should realize that these are the some of simplest tests, often requiring minimal clinical experience to interpret and very inexpensive. Yet they routinely overpay. Even if the price is considered "acceptable", chances are they were  overcharged anyway. 

Here are some basic information on 4 common labs and their usual reimbursement rates. If your Dr sends your samples to a non-contracted lab, or if you are out-of-network due to unforeseeable circumstances, you will now be better informed when negotiating those fees down. Hint: never pay the full price unless it amounts to your insurance allowable and you are directed to do so by your Explanation Of Benefits. 

1. CBC (Complete Blood Count) Code 85025

This is probably the most common lab test, routinely used by General Practitioners and Specialists alike. This test gives the clinical staff an overview of the health of your blood, and can detect certain underlining conditions (anemia, neutropenia) or acute needs (infection). 

It usually covers these readings: 

• hematocrit
• hemoglobin 
• mean corpuscular volume (MCV) 
• mean corpuscular hemoglobin (MCH) 
• mean corpuscular hemoglobin concentration (MCHC); 
• red cell distribution width (RDW) 
• percentage and absolute differential counts 
• platelet count (RBC) 
• red cell count 
• white blood cell count (WBC)

Learn more about this test at: http://www.nlm.nih.gov/medlineplus/ency/article/003642.htm

The average reimbursement rate is around $ 15.00 to $ 30.00. You should never pay more than 
$ 40.00 for this test if you are paying cash. 

2. CMP (Complete Metabolic Panel) Code 80053

This test is more detailed and provides your physician with a clearer picture of your organs' health. These are tested: 

• Alanine aminotransferase (ALT/SGPT); 
• albumin:globulin (A:G) ratio; 
• albumin, serum; 
• alkaline phosphatase, serum; 
• aspartate aminotransferase (AST/SGOT); 
• bilirubin, total; 
• BUN; 
• BUN:creatinine ratio; 
• calcium, serum; 
• carbon dioxide, total;
• chloride, serum; 
• creatinine, serum; 
• eGFR calculation; 
• globulin, total; 
• glucose, serum; 
• potassium, serum; 
• protein, total, serum; 
• sodium, serum

Learn more about this test at: http://www.nlm.nih.gov/medlineplus/ency/article/003468.htm

The average reimbursement rate if $ 20.00 - 40.00. You should never pay more than $ 50.00 for this test if you are paying cash. 

3. PT (Prothrombin Time) Code 85610

Those patients on blood thinning medication such as Coumadin or Warfarin are well acquainted with this test. It does not require blood to be drawn, and many patients can test at home via a device that sends the results to the lab and your physician. Used to monitor your blood's speed of coagulation, its long-term and regular use is necessary to adjust your medication dosage. 

Learn more about this test at: http://www.nlm.nih.gov/medlineplus/ency/article/003652.htm

The average reimbursement is $ 10.00 to 20.00. You should not pay more than $ 35.00 for this test if you are a cash patient.

4. Lipid Panel with LDL/HDl ratio (Cholesterol) Code 80061

Used as a screening tool for various conditions (hyperlipidemia, heart disease, obesity, renal or liver disease, and many others), this test is invaluable in evaluating risk factors as well as the effectiveness of a prescribed treatment. While they are more complex lipid tests, this is a most commonly used. 

To learn more about this test, visit: http://www.nlm.nih.gov/medlineplus/ency/article/003491.htm

The average reimbursement for this test is $ 25.00 to $ 40.00. You should never pay more than $ 60.00  for this test is you are a cash patient. 

5. Urinalysis (urine test) Code 81005

The most basic urine test, it uses special strips to detect bilirubin, and to screen for possible billiary, liver and other abnormalities and diseases. 

Learn more about this test at: http://www.nlm.nih.gov/medlineplus/ency/article/003579.htm

The average reimbursement is  less than $ 10.00. As a patient paying cash, you should never pay more than $ 20.00 for this test. 

NOTE: You may also be charged for a venipuncture (code 36415). Although most commercial insurance carriers deny payment as it is considered part of the service, Medicare allows reimbursement in the $ 4.00 range. You should not pay more than $ 10.00 if paying cash. 

Some of these tests do not require a MD to immediately review the results. For example, the ProTime test is routinely interpreted by nurses or medical assistants, who only consult the physician if the test results are out of the range that was determined at the time of the prescription of the medication. 

In any case, patients should not be put in a position of refusing or postponing a basic test such as those listed because of an exhorbitant pricing. Other labs can perform the same service, and many offices have the appropriate lab machines. Your PCP (Primary Care physician) may be able to perform a test prescribed by a specialist at low or no cost to you. It might be a good idea to ask when you are seeing that needle. 

©  [2016] Advimedpro.

©  [2016] Martine G. Brousse.

All rights reserved.

My objective is to offer you, the patient, concrete and beneficial information, useful tips, proven and efficient tools as well as trustworthy supportive advice as you deal with a system in the midst of sweeping adjustments, widespread misunderstandings and complex requirements. 

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