Wednesday, November 18, 2015

Billing for allergy skin tests

Suppose you want to do an allergy skin test for food and environmental allergies. This is where they poke your skin with little amounts of different allergens, wait 15-20 minutes to see how big a welt each one causes, and jot down the results. (The false positive rate is estimated to be 40% to 50% for many allergens, so there’s usually something to write down.) They also do two controls: histamine and saline. If you don’t react to the histamine, then there’s a problem. If you do react to the saline, there’s a different problem.

These are billed as procedure code 95004, with the number of units corresponding to the number of different allergens tested (plus two units for the two controls). It’s somewhere between $5 and $38 per unit, according to different numbers from Cigna at different times. But when you do lots of units, the difference starts to multiply.

Cigna knows the procedure code, but they keep that a secret. Cigna knows how the units are counted, but they keep that a secret. Cigna knows how many units you were billed for, but they keep that a secret. Cigna knows how much they pay different providers per unit, but they keep that a secret. The only non-secret is the total amount they settle on.

You can get the procedure code from the provider, maybe. Or you can get the procedure code from various web sites about medical billing. That’s also how you can find out how the units are counted.

You can find out the number of units you were billed for from the provider, and Cigna is willing to confirm that number.

Finding out how much Cigna pays different providers so you can comparison shop? Forget it. That would be treating health care like a rational marketplace, and Cigna refuses to enable that.

The non-secret is that the final total is $578.51 for 16 units of 95004. That’s $36.156875 per unit, which is obviously not the contracted price. It’s also a touch higher than the approximately $90 total that Cigna said it should cost from this provider. And only 13 tests and 2 controls were done, so the number of units is overbilled.

Fortunately, I called Cigna and got this straightened out, with a clear explanation for what went wrong.

Cigna won’t answer any questions.

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