u/Many-Coach-6880

State: New Jersey

** EDIT: specialty I’m seeking help for is POTS**

I finally found a specialist for a medical condition I've been urged to get diagnosed, and they accept most major insurances (including mine). Well scheduling, I was informed that there was a mandatory out-of-pocket test I'd have to take or else the doctor wouldn't see or treat me. I let the staff know he's actually tier one in my insurance so I shouldn't have any out-of-pocket costs. They said this test "doesn't have a CPT code" and for the specialty I'm being referred for, it is required by this doctor and their office. It's $250.

Now while this diagnosis is not particularly a rare illness, specialists are extremely hard to find. Usually 1-5 specialists in the entire state - and nonspecialists 99% of the time will not even discuss diagnosis. In my area, he is 1 of 2 in this specialty.

Is this illegal? I get having a preferred test that insurances may not fully recognize or cover - but making it required prior to receiving any treatment? It feels like extortion but I don't know enough about the legality of this kind of thing to say.

State: New Jersey

I finally found a specialist for a medical condition I've been urged to get diagnosed, and they accept most major insurances (including mine). Well scheduling, I was informed that there was a mandatory out-of-pocket test I'd have to take or else the doctor wouldn't see or treat me. I let the staff know he's actually tier one in my insurance so I shouldn't have any out-of-pocket costs. They said this test "doesn't have a CPT code" and for the specialty I'm being referred for, it is required by this doctor and their office. It's $250.

Now while this diagnosis is not particularly a rare illness, specialists are extremely hard to find. Usually 1-5 specialists in the entire state - and nonspecialists 99% of the time will not even discuss diagnosis. In my area, he is 1 of 2 in this specialty.

Is this illegal? I get having a preferred test that insurances may not fully recognize or cover - but making it required prior to receiving any treatment? It feels like extortion but I don't know enough about the legality of this kind of thing to say.