02 Sep A Routine Denial
By David Marcovitz
When I was a second year medical student, I gave blood at a Red Cross drive and noticed a week later that I had a hard and slightly tender blue spot on my left forearm arm where they had drawn blood. I described it to my PCP through our online portal, and I mentioned that I’d had a similar occurrence a couple years prior after having an IV during an episode of severe dehydration. He called me an hour later to suggest I start taking aspirin and see him the next day for what sounded to him like a superficial venous clot. I still remember that my girlfriend and classmate at the time (who is now my wife) was out on a jog and came running to the library with a small bottle of aspirin that she had picked up on her way at a local pharmacy. We joked that she had probably saved my life.
I went to see my PCP at student health the next day, and after taking a history and examining me, he decided to order a hypercoaguability panel, a set of lab tests used to diagnose a small number of inherited and acquired conditions that put one at increased risk for having blood clots. He called me when the results were in to tell me I was “heterozygous” (less severe than homozygous in this case) for a fairly common mutation called Factor V Leiden. He referred me to a hematologist for further discussion about the condition.
From a financial perspective, things started to get interesting when I received a bill from our student health insurance company stating that I owed $2000 for the genetic test used to diagnose my Factor V Leiden. I called up the administrator (a separate company) that handled all the claims, and I told them that according to the benefits guide, diagnostic blood tests were covered. They told me that the test for Factor V Leiden was a “genetic screen” which they did not cover. That didn’t make sense to me since I believed my doctor had ordered a diagnostic test based on a specific set of signs and symptoms (my PCP would later agree). But despite my sticker shock, the claims agent didn’t seem to share in my alarm. I realized quickly in talking to him that denying payment for this test was a very routine thing and that he had nothing further to say about it. He told me I would simply need to submit an appeal and include a letter from my PCP.
The appeal was submitted and within a few months, a received a new and adjusted bill from the administrator asking only that I pay the usual 10% of the cost for the test – my appeal had been a success. But what struck me was that I wasn’t asked to pay ten percent of $2000, but rather ten percent of $375. The hospital wanted $2000 from me for the test, but they only wanted $375 from the insurance company. I would later learn that these bizarre contracts are common as well.
Indeed, the hum-drum nature of the whole sequence of events for everyone involved but me was like an inside joke that I was woefully on the outside of, frantically calling my parents when I received the initial bill to see if they could help me with the $2000 price tag and later entertaining visions of taking my bill directly to the Dean of my medical school and calling for a press conference. But the company threw a wet towel on my incendiary plans – this was just a routine denial, perhaps an attempt to save a few hundred dollars here or there – and I was only left to muse that there has to be a better and more transparent way for these companies to bill their clients.
David Marcovitz is a second year resident at the MGH/McLean Psychiatry Residency Program in Boston, MA.