Question about cost of a biopsy

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I would forst ask what the arrangement is between GI doc and CDx. Second question to ask the pathologist is why did he do upfront staining on all the biopsies?
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Pathbusiness said:
I would forst ask what the arrangement is between GI doc and CDx.
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I am late to this discussion, but that bill is obviously exorbitant.

Your GI doctor owes you an explanation, and should attempt to get the bill reduced on your behalf. I agree with pathbusiness--I would ask whether he or his company have any financial incentive to send work to CDx. This can be a lot more complicated and difficult to detect than it might seem. There are any number of financial arrangements out there that, while unethical and potentially abusive, are not necessarily illegal. For example, in addition to the usual in-office lab arrangements, there are labs now offering fractional "ownership" to clinicians in jointly held lab companies. The profits distributed from lab ownership are not directly tied to the volume or value of referrals, and, in many of these arrangements, government payer work is specifically excluded.

It may be that there is no financial arrangement or unethical behavior, and your GI doctor is just clueless. In that case, he or she should at least be made aware of the ridiculous bills that are getting dropped on his/her patients.
 
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Light Yagami said:
This is so basic but hasn't been really addressed yet. So, when a healthy young person with no PMH complaining only of dysphagia with no weight loss goes in for an EGD with biopsy, what is the normal, widely accepted reimbursement rate for the biopsy component in total (what insurance pays + what the patient pays)?
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I don't think there is a "normal" amount, really. The pathology bill will vary widely based on insurance carrier, patient deductible, network status, and (obviously) on how many specimens are submitted for evaluation. If I were going in for an endoscopy, I'd make sure that my specimens were sent to an in-network lab.
 
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UPDATE:
I spoke with the GI Doc. He told me that he uses CDX Diagnostics in cases of questionable Barrett's dx to confirm. He knows insurance won't cover it, but he said CDX policy is to take whatever insurance pays and won't make the patient pay anything. So he said "disregard that statement". I found this suspicious, since if insurance won't pay, it won't pay. So how does CDX get paid then? I didn't press him on it. Next, he gave an explanation of why the Orlando pathology group charges so much "costs so much to run a path lab, etc.". He said he would speak with that pathologist and try to get a professional courtesy discount. I'll wait and see what happens.
 
Light Yagami said:
UPDATE:
I spoke with the GI Doc. He told me that he uses CDX Diagnostics in cases of questionable Barrett's dx to confirm. He knows insurance won't cover it, but he said CDX policy is to take whatever insurance pays and won't make the patient pay anything. So he said "disregard that statement". I found this suspicious, since if insurance won't pay, it won't pay. So how does CDX get paid then? I didn't press him on it. Next, he gave an explanation of why the Orlando pathology group charges so much "costs so much to run a path lab, etc.". He said he would speak with that pathologist and try to get a professional courtesy discount. I'll wait and see what happens.
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Interesting. It certainly isn't your problem--good for you if you can get CDx to write off your bill--but, waiving out-of-network charges may represent prohibited remuneration under anti-kickback statutes. See https://oig.hhs.gov/fraud/docs/advisoryopinions/2015/advopn15-04.pdf and New OIG opinion could have implications for how labs charge patients
 
This is a fraud typical of these kind of companies(CDx and toxicology screens, drug level monitoring etc). They will have a grossly inflated bill, insurance pays 10% of it and the rest is written off. Your GI doc indirectly told you what the game is!!
 
But him doing six biopsies and the lab doing special staining on all of them is a different issue you need to address.
 
Yes I will see what the final bill he gets for me from the path lab is and then go from there. When I brought up issues with the pathologist and why were special stains done he replied he has no say in what the pathologist does and that everything was done in the pathologist's lab so I should speak directly with the pathologist if I have an issue with the biopsy. He also mentioned the pathology group is hospital affiliated so they really care about their reputation and actually charge less than other local private pathologists!
 
Whatever he told you is BS. The report is on a GI letterhead and clearly states that technical work is done at their office in a leased space. Believe me the pathologist has no say in performing special stains, if he does then he is equally guilty. They are all done upfront. The diagnosis is made later to justify them. This is a typical case of TC-PC split. "Conflict of interest" goes flying out of the window. You should not have been charged more than $300 for pathology services if it were done right.
 
The pathology group used was pathology specialists, pa which provide services for orlando health: About Us

Pathbusiness: If the GI doc is basically dictating what services for the pathologist to perform, how is he getting paid more? My $2700 bill was from Pathology Specialists, PA. Is he getting paid back "under the table" or in some referral fee? Is all of this legal?
 
Your pathology report is on Orlando Gastroenterology letterhead. Its written on it that technical component was performed at their address. At the end of the report there is a footnote which says slide interpretation was performed at space leased by ORHS. In my understanding the GI group is raking the TC and part of PC by leasing space for slide interpretation.
It is one of those scenarios where a GI group has their own lab and has contracted one of the local pathology groups or a part time pathologist to read slides at their site. How they split the pot is an accounting jugglery. Is it legal? Hell no. Is it common? Yes unfortunately.
 
Pathbusiness said:
Your pathology report is on Orlando Gastroenterology letterhead. Its written on it that technical component was performed at their address. At the end of the report there is a footnote which says slide interpretation was performed at space leased by ORHS. In my understanding the GI group is raking the TC and part of PC by leasing space for slide interpretation.
It is one of those scenarios where a GI group has their own lab and has contracted one of the local pathology groups or a part time pathologist to read slides at their site. How they split the pot is an accounting jugglery. Is it legal? Hell no. Is it common? Yes unfortunately.
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Whistleblow on these mfers.

If the OP tattles to the feds, will he be rewarded treble?
 
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He will be awarded 25% of the recovery. The penalties are actual loss plus treble damages plus at $11K civil monetary penalty for each fraudulent claim.
 
Pathbusiness said:
He will be awarded 25% of the recovery. The penalties are actual loss plus treble damages plus at $11K civil monetary penalty for each fraudulent claim.
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If the practice does this on a regular basis, will the OPs reward include those as well? Surely this will trigger an audit.
 
I have considered it. On the one hand, what these people are doing is wrong and if I as someone in the field am having a hard time dealing with them imagine what the average layperson goes through? On the other hand, I'm about to apply for residency and I don't really want to get my name out there as someone who "rocks the boat". I wonder how residency directors would view a candidate who is part of a whistleblower lawsuit?

Also, can we be sure the GI doc is doing this for his medicare/medicaid patients? I'm pretty sure he isn't using CDX diagnostics for them. I don't have proof that he is running unnecessary stains and billing excessively for his medicare/medicaid patients and that's what a whistleblower suit requires.
 
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My advice would be to get your charges waived by these crooks, report it on CMS complaint hotline and move on. Whistleblower suits are a very long fight, require attorneys, and a lot more proofs and first hand knowledge of the fraud. At the end of the day these guys are not big enough to pay even seven figure fines.
Just don't take it lying down.
 
@Light Yagami Any update?
I suffered from abdominal bloating, discomfort, nausea, loss of appetite (no significant weight loss), chest pain, chronic dry cough and low grade fever for about 3 months. My PP ran blood work that came back negative or anemia or any liver/pancreas enzymes. I was referred to an in-network gastroenterologist who performed an upper endoscopy and colonoscopy. They provided me with a diagnostic code and I provided it to my insurance which confirmed it was covered.

I had biopsies taken and was diagnosed with Barrett's Esophagus. I am a 25 yr old Asian female located in Hawaii, US.

I got several reasonable bills totaling $1,200. But I just received a notification from my insurance that one of the biopsies was sent to Oral Cancer International Inc that was out of network. The total is $4,384.18, which was almost exactly as much as yours! I am waiting for the bill to contact the lab and I have already emailed the gastroenterologist to ask why I was not notified that they would use a non-participating provider (the lab, possibly CDX related).

Please let me know how you're settling your bill!
 
Just break yourself. Docs, community hospitals and academic hospitals need to get paid.
 
Pathbusiness said:
Whatever he told you is BS. The report is on a GI letterhead and clearly states that technical work is done at their office in a leased space. Believe me the pathologist has no say in performing special stains, if he does then he is equally guilty. They are all done upfront. The diagnosis is made later to justify them. This is a typical case of TC-PC split. "Conflict of interest" goes flying out of the window. You should not have been charged more than $300 for pathology services if it were done right.
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I think the false claim act for sure and most CMS rules would probably not apply here.
That's because it commercial insurance. The insurance company policies and state insurance law would like apply.

There appears to be other things that I find most unusual. .
If the reports is on the GI doc's letter head then they have to bill what they did.

In this case, the report suggest that at least the GI practice is doing the professional service and is responsible for billing it. Did they bill you ?

The technical component was performed at the GI practice location under a lease arrangement ?

I am not sure who own's what here and therefore who should bill.

BTW, a lab can lease can space and it can be legal even for Medicare.
The leased space has to be at a market rate with no ties to the service volume. Nevertheless, this is a unusual setup and perhaps worry some arrangement in this situation.

Clearly they are making some attempt on the report to showing where the services are performed. This is CLIA a requirement.
If you want to find out who own's what. There is a CLIA look up tool.

You might find two labs with CLIA certificates. One for the PC lab and the TC. The owners will be stated.
That is a federal requirement.

You don't have Federal whistle blower case, regardless. This under different law.
 
Rnw808 said:
@Light Yagami Any update?
I suffered from abdominal bloating, discomfort, nausea, loss of appetite (no significant weight loss), chest pain, chronic dry cough and low grade fever for about 3 months. My PP ran blood work that came back negative or anemia or any liver/pancreas enzymes. I was referred to an in-network gastroenterologist who performed an upper endoscopy and colonoscopy. They provided me with a diagnostic code and I provided it to my insurance which confirmed it was covered.

I had biopsies taken and was diagnosed with Barrett's Esophagus. I am a 25 yr old Asian female located in Hawaii, US.

I got several reasonable bills totaling $1,200. But I just received a notification from my insurance that one of the biopsies was sent to Oral Cancer International Inc that was out of network. The total is $4,384.18, which was almost exactly as much as yours! I am waiting for the bill to contact the lab and I have already emailed the gastroenterologist to ask why I was not notified that they would use a non-participating provider (the lab, possibly CDX related).

Please let me know how you're settling your bill!
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Update:
CDX Diagonistic is considered "not in network" but they're in the process of becoming "in net work" for many major insurance companies. So for now, they will except whatever payment amount my insurance company is willing to pay. In this case $600.
My insurance company was unaware of this and the notify I received by them was incorrect. CDX contacted my insurance and worked it out!

...medical insurance companies are so misinformed.
 
Ha Ha, thats why.

EndoCdX the biggest load of manure ever cooked up. Of course your GI guy is getting a kick back from them. In the hundreds of biopsies I've diagnosed I've never had EndoCDx say anything otherwise saying they had dysplasia when I didn't see it on biopsy.

It's a load of crap. YOU need to be vocal and loud about this, it goes to show how patients need to inquire about this before they send to random labs. You can chose what lab to send your biopsy to, that is your right unless insurance says otherwise.

I even emailed one the GI experts and asked about their opinion of EndoCDx and they said it was solely a $$$$ decision.

Good luck!
 
Not sure if anyone is still watching this thread, but I found it very enlightening. I just had an endoscopy performed in Irvine, CA, and have received an EOB from my insurance stating that they don't cover CDX diagnostics - and won't cover their entire bill of *get this*: $4384.18, but rather $440 of it. I haven't seen a bill from CDX yet, but thanks to this forum I have a plan for how to handle it when I do. I would love to hear what the result of your situation was, if you ever read this!
 
KGHB said:
Not sure if anyone is still watching this thread, but I found it very enlightening. I just had an endoscopy performed in Irvine, CA, and have received an EOB from my insurance stating that they don't cover CDX diagnostics - and won't cover their entire bill of *get this*: $4384.18, but rather $440 of it. I haven't seen a bill from CDX yet, but thanks to this forum I have a plan for how to handle it when I do. I would love to hear what the result of your situation was, if you ever read this!
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This sure exactly like the 'toxicology screen", and pain management scam.
 
KGHB said:
Not sure if anyone is still watching this thread, but I found it very enlightening. I just had an endoscopy performed in Irvine, CA, and have received an EOB from my insurance stating that they don't cover CDX diagnostics - and won't cover their entire bill of *get this*: $4384.18, but rather $440 of it. I haven't seen a bill from CDX yet, but thanks to this forum I have a plan for how to handle it when I do. I would love to hear what the result of your situation was, if you ever read this!
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Same thing for me. I had an endoscopy on the 6th of March and received an EOB showing quest is charging $4384.18. My Insurance is only paying $360. Any updates? OP "Update" post 5/31/14 about CDX policy not to charge customer gives me hope but I don't want to have to worry about this all weekend before I can call doctor/lab/insurance Monday. Thanks
 
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