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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?
I would forst ask what the arrangement is between GI doc and CDx.
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)?
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.
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.
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.
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.
@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!
This sure exactly like the 'toxicology screen", and pain management scam.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!
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!