End of the road fighting insurance?

I posted back in January (link) that my insurance company refused to pay a lab bill for a PCA3 test ($600) that my surgeon ordered prior to surgery.

The insurance company claimed that since I was already firmly diagnosed with PCa via biopsy, that the PCA3 tests was unnecessary.

My surgeon wrote a letter to appeal the refused coverage, claiming that the PCA3 test is also useful for choosing a treatment plan, even after diagnosis has already been done.

The insurance company's Urology Physician consultant reviewed my surgeon's appeal letter, and concluded that the PCA3 tests was still unnecessary and the insurance company is refusing to pay the $600 bill.

What are my options now?
1) Negotiate a better price with the lab and pay the bill? (Perhaps ask the insurance company what their "negotiated rate" would be if they had covered the test, and offer to pay that amount to the lab.)
2) Complain to the surgeon's office that they ordered an unnecessary test and see if their office will agree to pay some/all of the bill?
3) Give up hope and pay the $600 bill (which is waaaay more than the total amount I paid out of pocket for my entire PCa diagnosis and treatment combined!)
4) Other? (Help!)

-Gedman

Id be interested in the rational of your surgeons claim. Sorry, nothing personal, but I thoroughly understand the Insurance companies point. And without knowing surgeons rational, IDK. Did your surgeon willy nilly add that to your blood work or did you agree to it. If willy nilly, your option for reduced rate, in my view has better odds with your surgeon. Im not sure I would even negotiate, His mistake, he eats it. If you agreed your only option is with insurance company. a medico, can not just order any test he wants, and stick it to you if ins. doesn't pay. The billing folks know how to code and when to code. If it doesn't fly. your surgeon has the problem with the Ins co, not you. I f you want to stay in good standing with this surgeon, present this argument to him, he will negotiate lower with you. Again this is only viable if you did not in anyway agree to a pca3 test. If you did, game over its your problem with Ins co, and possibly with your surgeon. FWIW.

I've been stuck with your #3 option many times. Such is life in America.

I had the issue most recently with a genetic test that found and confirmed a genetic mutation I and my siblings have. That blood test was $1000. When the test came back positive for the MTHFR mutation, also known as the motherf.... mutation among my siblings, I was immediately referred to a few specialists and told to bring my children too. I was put on certain supplements and lifestyle changes but apparently the test that lead to all this wasn't considered necessary by the bean counters.

#2 sounds most reasonable at this point

As suggested earlier sometimes the lab will accept the same amount as the insurance would have paid. This is generally much lower than the so called "market rate". My insurance recently did this for me. The lab sent in the bill for pathology but it was not covered (in my case deductible not met) but the reimbursement to the lab was noted as the insurance company rate. That is what I paid the lab. By the way this is a negotiated rate.

Good luck,
Don

I can't recall. At the time I took it, Umich said it was ready for prime time, but I don't think it was approved yet. So maybe Umich paid some of the cost.

It was not much for me out of pocket

Mel

The insurance company has an appeals process. Find out how it works and what your rights are. Call the surgeon and let him know the test is on him because he ordered it without getting prior approval form insurance. Hopefully he will be more helpful with the appeal if he knows you are going to contest the bill. Have him tell you all the times he has ordered the same test and evidence that insurance covered it. That information will help with the appeal. He will not reveal patient identifying information, but if he can show a pattern of getting the test reimbursed, that will help. Contact your state insurance comissioners office and find out whether there are complaints similar to yours and how they were resolved. This information may help your appeal.

A few months ago I went through the process over a 4 month process that ended with an 30 minute interview with a panel that included a doctor, nurse, and attorney. I stated our case and presented our facts and then was questioned by the panel. I included the fact that the test (an MRI) was ordered by the hospital without insurance approval. A few days later the appeal went in our favor and the insurance covered the test. The decision was about 6 months after the procedure so it can be slow and many steps.

The surgeon already filed an appeal with the insurance company (as described in my first post above), so he's aware of what's transpiring. The insurance company rejected the appeal, restating their view that the test was medically unnecessary post-diagnosis.

I don't think the surgeon will know how many times the test has been paid by insurance for his patients. He just sends blood/urine to the lab and receives test results. The claims/payment is a matter between the member (me) and the lab directly.

Two useful things I learned today:

• A bit of online homework found that Blue Cross/Blue Shield (link) and Aenta (link) will not pay for PCA3 tests for prostate cancer patients because they deem the test to be "medically unnecessary".
  
• My employer has a 3rd party "patient advocate" service to help employees resolve insurance-related disputes between the employee and providers. I've scheduled a meeting to discuss my issue with the advocate. I like the idea of using the advocate as my bulldog in dealing with the surgeon, as a buffer to avoid damaging my relationship with my surgeon.

-Gedman

Gedman,

Sorry for the delay, but I still owe you an answer on this. Hope to have more information for you by Friday.

Also, I would recommend the third-party advocate. I have heard they can be very useful.

brooklyn/Jerry - Thanks to you both.

I spoke with the advocate. She is getting involved. First step is for her to gather all the relevant info from the insurance company, then she'll deal with trying to get the surgeon to pay the bill. If that fails, then she'll help negotiate a better price with LabCorp.

-Gedman

Finally have all the information to respond. NYP hadn't sent all of my records to Tewari's new office, despite my request that "entire file" be sent to them back in October...took a bunch of insistent calls but got that done. So, post-biopsy (4+3) and pre-surgery, the PCA3 was ordered and probably done by LabCorp. They charged my insurance (BCBS, but not Anthem) $570 for an "unlisted molecular pathology procedure for malignant neoplasm of prostate" which most likely is for the PCA3. However, my insurance did not pay anything, nor was I charged anything, as I was told by the insurance company that they "needed a proper code" from the lab. It seems the lab never sent that in. So, if they do, the insurance might pay something. But, since I met my 2013 out of pocket max, it doesn't appear that I would have to pay if that happened.

I can see the dispute here....PCA3 seems to be mostly for people with negative biopsies, or those undergoing active surveillance. But, others believe it might have some value. Our highly regarded doctor ordered it. If patient advocate doesn't have any luck, then I would hope doctor would consider paying most or all of it.

Interestingly, my PCA3 was 19, with under 25 being normal, so glad that I had an agressive urologist and got the biopsy when I did.

Hope this provides some helpful information. Good luck!

In its Spring 2014 update to "prostate Disorders" Johns Hopkins, specifically Alan W Partin, MD, PhD says on page 7 uder "tests to Ruel out a repeat biopsy:

"Progensa. This urine test detects the presence of a gene called Prsotate Cacer antigen 3 (PCA3) . The gene is overexpressed (or overactive) in 95% of men with PCa but not in men who have healthy prostates or BPE. Results are ranked from <5 to >100 with a score of <25 indicated a decreased likelihood of a positive biopsy.

Progensa is approved for use in men age 50 and older who have had one or more negative biopsies, but who a doctor nonetheless suspects may have PCa."

So part may be useful but age 42 works against you. So you may nbot want to go outof your way to quote that age 50+ portion.

What better way to spend your April 3 anniversary than fighting with insurance companies. My one year anniv on Lupron also from 3-28-13 but so far no issues with insurance who is paying out big time for Lupron every 4 months @ 24 K and Xgeva monthly @ 8K to tune of over $ 168 K a year.

LupronJim

Gedman, any luck on fighting this charge?