7 Weeks into TRT Protocol

I get a script or a form they use where they Check off labs.

I check off additional items I want or write them in at home. Lab never questioned.
And dr does not remember what they ordered anyway.

The issue you can run in is that the dx code, you will see on script, is used by insurance company to cover labs ordered. Many times the dx code already on covers the additional things I write in.

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Those are CPT codes, Current Procedural Terminology, and the insurance carriers base payment on the particular code. The procedure code needs to match up with an ICD (International Classification of Diseases) code, or diagnosis, for payment to be approved. There is an entire profession that does coding, Certified Medical Coder (CMC) or Certified Professional Coder (CPC). The doctor does what they do, documents it, renders the diagnosis, and the coder figures out how to code it and therefore bill it.

Essentially, it’s another layer of staffing necessary to function in the insurance game. There are seminars for doctors that teach what to do and how to document it to qualify to bill a higher service level, and therefore, more payment. Sometimes, it’s as simple as asking one question and documenting it, bumps the service up to the next level.

What you have is an example of exactly what I was referencing. You had blood work of which the charge from LabCorp was $1198. LabCorp is in your carrier’s network, so your “rate” turned into approximately $185. Nice. Even better, none of that was applied towards your deductible which you have either already met this year, or lab services are not applied to the deductible as part of LabCorp’s agreement with the carrier. Plus, there is no co-pay or coinsurance, like 20% of the member rate applied, which means you’ve either met your out of pocket limit for the year, or there is no out of pocket expense for labs.

Obviously, a great deal for you, cost to you is nothing. Insurance paid around 15% of the amount billed. We pay about 10% of what Quest would bill. A potential drawback with insurance vs provider payment is if they would not allow a particular test, or certain tests to be repeated, or tests for patients getting treatment for something not allowed, like test when your levels are 400.

On the other hand, the reimbursement is such a small percentage, they just pay it. They (insurance carrier) do not want you cancelling coverage with them or you, and other employees, bitching to the company’s HR department until the employer goes elsewhere for employee benefits.

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Correct, mine is $0 out of pocket (ever) for labs, if done at LabCorp… doesn’t matter where you’re at deductible wise, etc. My insurance was pretty good this year, $1000 deductible but they actually reimburse you for the first $500, so you only pay the $501 to $1000 portion, then I get 90% coverage until I hit out of pocket max of $3K. Next year it’s $500 deductible but they don’t cover any of it, so the first $500 will be on me (labs are still excluded and 100% covered)

One year we had a $250 max out of pocket, so literally $250 for the year and you’re done, everything else is covered for free. That didn’t last long.

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They don’t take insurance. I simply pay $295 every 2 months for 10ml Cyp and they also give me labs 2x yearly.

There is only one page, your not missing seeing another

Can I check to see if insurance will be covered there before doing anything with them?

This is all so confusing to me, when I’m using a clinic that takes no insurance this all becomes irrelevant correct?

The contract I entered doesn’t even spell out how often I can get labs… does this seem like a waste?

Probably. I know there is a pre-approval process for most insurance companies. I’m looking at pretty big sinus surgery and the office called and got it approved through insurance beforehand since it would be like $50K+

The problem is you’re going to have to find a doc to actually order the labs through them, kind of like writing a prescription, and I have no idea if the doc you’re working with would be willing to do that… For Defy to do it I had to sign a bunch of stuff saying I understood whatever insurance didn’t pay for was on me and blah blah blah before they would do it, but ultimately they did do it

Well my clinics Dr. will not do that. I’ll wait a few months till I can walk away and look at joining Defy

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Yes, it is confusing and yes, irrelevant if insurance is not involved, which would explain why many opt to not bill the patient’s insurance.

This is why I had the business staff avoid the fine print contracts. We take our fees, prescription fees and projected lab fees for a year, divide by twelve and do the same thing, monthly debits. Downside is there are many varying plans and fees of which I couldn’t begin to remember the costs, but staff handles that. It is made clear that added prescriptions will increase the monthly fee, and also anything eliminated or decreased will lower it.

They get unlimited contact with me, office visits, zoom or phone calls. Very, very few abuse that, though some will call me because the are a day late with their injection and are freaking out because they read on a forum somewhere that they are now “unstable” or in a state of “chaos”…

They get any labs needed, so if something changes and they need more they simply get them. Costs us more, but it evens out as some guys are delinquent in getting their labs so we come out ahead. That is one reason we do it this way, no reason not to get labs, you are already paying for them.

If something weird comes up…like a request for STD testing since some of the guys find themselves returning to their youth, they pay extra for the test.

A lot of ways to do this, I know one who charges $1500 for the first year, $500 a year thereafter. Patient is on their own for getting labs and prescriptions, though he does give a list of pharmacies and labs that they can use, but they do not have to do so.

Damn COVID, this is a phone call follow up day and they are having tech issues so the web site has been down since yesterday, and will be until Monday. I have zero access to labs.

That is awesome. My biggest complaint with defy is there is very little access to their docs without paying for another consult.

My 90 day lab is in January. I asked about Free T levels and they said for $45 I can add that to the lab instead of just Total T. Is it worth me paying the additional $45?

I found this one where you can get total T, free T and HCT all for like $62, but everything I’m finding for only free T is more than $45, so probably not a bad price for it IMO

Is a free T # that important to have or will total t suffice?

Total T and SHBG would be fine too, you can calculate free T from that. But, yeah, free T is important. Some would argue it’s the most important.

It was $90 to add total T and SHBG to the labs they are doing at the start of January. I figured since I’ve never had those two tests ran before why not.

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