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Posted 4/27/2018 11:18 PM (GMT 0)
I've been thinking of starting this thread for a while. Our sticky for the newly diagnosed is a great boot camp on the medical side of PCa, but doesn't say much about how to navigate insurance on the long journey. While some newbies have already gone through the "major medical" school of hard knocks for other serious diseases, many (most?) of us have never had to deal with our health insurance for much more than yearly checkups and blood tests. If others agree that a primer on insurance would be a good thing, please chime in and say what you've learned along the way that you wish you'd known when you started. I realized that there are lots of different plans, that the Medicare and VA crowd may have unique issues, as will non-US members. Still, there may be some commonalities as to what to be on the lookout for and how to avoid getting burned.

I've had three such lessons myself, on BC/BS:

--A $900 denial of benefits for visits from an internist during my RP hospital stay. The hospital was in plan, and the surgeon was in plan, but this one doctor, dispatched by the hospital, was not.

--A $5,000 denial of benefits for a Decipher test that the surgeon ordered without my knowledge or approval.

Those two items I haven't been billed for yet by the doctor/hospital or GenomeDx, so I've held off fighting them. The third was my bad and I'm sucking it up:

--Axumin PET scan that I probably didn't need. Copay $100, plus 25% of the cost of agents. Well, the agent costs several thousand dollars, so I'm responsible for about $1,000.

Not sure how this can be turned into advice for newbies, but if others have had similar experiences, maybe we can come up with something.
Posted 4/27/2018 11:31 PM (GMT 0)
Great idea Saipan. Here are a few things I have learned.

My urologist's fusion biopsy request was denied by UHC. The first reason was non-sensical. After several calls and discussions with UHC, and a separate discusion with another radiologist, the denial made more sense. The fusion biopsy would have been approved if I was getting high PSA scores, but negative biopsy results. The MRI / Biopsy also would have been approved for a recurrence after treatment. That was not my situation. Different parts of the country may vary on this for UHC.

The Prolaris test was interesting. The Urologist ordered the test after my 2nd biopsy. I told him that I heard it was expensive. He said that medicare covered it, so he thought UHC would cover it. Wrong. The prolaris test required pre-approval. After the test, I received a notice from UHC that this was not pre-authorized. However, they also stated that the urologist could not bill me for the test because he did not get pre-authorization. I thought this was very fair to me since I knew enough to ask the question. The bill was $3,900.
Posted 4/28/2018 12:13 AM (GMT 0)
Richard, if you get billed by GenomeDX for the Decipher test, call them. My understanding is that they are committed to not charging anyone over $400 when insurance doesnt cover it. I think it might have to do with the advantage they have as their database grows larger and larger, but i could be wrong about that.

I'm on Medicare now, and have had no issues whatsoever. I am guessing that could change, should i ever find myself with advanced PC. Hope i never find out.

Before i was diagnosed though, i had Emblem Health. 6 months after my first biopsy which was negative, i changed URO's and my new uro wanted an MRI. Coverage was denied. I told the Dr that if he thinks its really important that i have one, i would pay the 2-3k out of pocket. But he said no, not to worry.
Two years later i was diagnosed, and my surgeon, did a pre-op MRI. After the surgery, he told me from the MRI, he had a strong feeling i would be upgraded, and sure enough i went from G6 to G7,

If i had known then what i know now, i would have, after one more subsequent PSA rise, paid for the MRI a year before diagnosis, then fought with the insurance company. Might have made a difference, might not, i dunno, but it would have been nice to be diagnosed a year earlier, considering the uro told me that the cancer was likely there when i had my first negative biopsy.

Live and learn
Posted 4/28/2018 12:19 AM (GMT 0)
SP-

That's so frustrating and expensive!

I have no idea how you're supposed to know that the hospital brought in an out-of-plan internist. It seems like you did due diligence in getting an in-plan hospital and surgeon. Maybe your insurance will be responsive if you explain in writing - at least they may be willing to negotiate on the bill.

You may be able to protest the Decipher denial - at least get an explanation from them as to why.

The Axumin scan brings up a whole other subject - with patient empowerment comes patient responsibility. I've seen on this site and others, patients and their doctors asking for expensive tests that are not likely to change any treatment decisions, justified solely on the basis that it would be "nice to know." Even if a test might change a treatment decision, I think the patient has to assess the probability that it will in his particular situation.
Posted 4/28/2018 3:11 AM (GMT 0)

Pratoman said...
If i had known then what i know now, i would have, after one more subsequent PSA rise, paid for the MRI a year before diagnosis, then fought with the insurance company. Might have made a difference, might not, i dunno, but it would have been nice to be diagnosed a year earlier, considering the uro told me that the cancer was likely there when i had my first negative biopsy.


Same story here. I wonder how many others went undiagnosed because of the no MRI before biopsy rule.

In my wife's case, we paid for an MRI - which showed a spinal tumor. Insurance still denied payment for it. Without it she would have been paralyzed by the time someone finally figured out her rare form of lymphoma.

We actually DID know what we didn't know a year earlier. The PCa was a lesson learned.
Posted 4/28/2018 3:56 PM (GMT 0)
They are not billing you the 900 because of their intra facility and inter facility lack of communication( not my job)...which is standard in all institutions in todays world...name me one...it ain't...worked to your advantage this time...do not pay ...do not inquire or pay... ps love the shift of flow of...{it ain't}... tho without purpose...still...it fits the times
Posted 4/28/2018 11:39 PM (GMT 0)
I received my Prolaris bill in the mail today. The $3,900 charge was denied by UHC because it was not pre-authorized. Now Prolaris is asking me for $375. Hmmmmmm. So the price is 1000% higher if insurance pays....

The Uro asked for this test. I did not. I even asked if it would be covered by UHC, since I had heard that it was very expensive. The Uro thought it would be covered.

Not sure yet what I will do.

If your MD offers the Prolaris test, make sure that you get pre-authorization.
Posted 4/29/2018 12:47 AM (GMT 0)
Its a mess..." the servant problem is just the tip of the iceberg Agatha" Whot???
Posted 4/29/2018 12:01 PM (GMT 0)
HARD LESSONS LEARNED:

#1 - Get an MRI, even if you have to pay for it yourself (four posts up).

#2 - Never pay the hospital in full, at least not right away.

Following my wife's ER visit and subsequent hospitalization, when her lymphoma was diagnosed in December 2016, we had a $6000 deductible. So I wrote a check to the hospital for the full amount, thinking okay, this will take care of our deductible and everything will be paid from here on out.

Then in early 2017 we were getting bills from labs and doctors and such, and insurance EOB's stating "deductible not met". After numerous phone calls we found out that the hospital, which is THE major hospital in the nearby city, had billed the insurance company first without reflecting my $6000 check. They were keeping ALL of the money and eventually we found out that we had a credit balance at the hospital that they were applying to her ongoing chemo treatments during the following year.

Meanwhile, all the radiologists and pathologists and such who hadn't billed so quickly had the deductible, uh, deducted from their insurance payments. Eventually we got a check from the hospital for $3500 to make up for all the double payments they had been hoarding.

But in the meantime, it was a real mess for us, especially as her treatments spanned two years and also two different insurance plans. What we should have done is paid the hospital "some' money and waited for the big bill from them, as we paid off the piecemeal labs and doctors.

So, lesson number two is Never pay the hospital first.
Posted 4/29/2018 12:48 PM (GMT 0)
I was prepared for a huge hassle with Medicare and our supplemental insurance, bills and/or statements flooding our mailbox every week for my 'triple play' adventure. To my surprise every statement of services said nothing due (MD Anderson.) I think my out of pocket expenses were less than a hundred bucks or so. Apparently MDA accepts medicare and supplemental as full payment. A pleasant surprise in a very unpleasant journey.
Posted 4/29/2018 2:06 PM (GMT 0)
I’ve been on Medicare plan G for part B and have Medicare part D through Silverscript. My plan B supplement is with Mutual of Omaha. I’ve had lots of treatments for PCa , the major ones listed below in my signature. I’ve never paid anything except the annual Medicare Part B deductible which is peanuts. I’ve also paid the Medicare Part D co-pay for meds of course but lately have reached the out of pocket maximum early in the year due to the high cost of trelstar and xgeva. So I’m very happy with my insurance.

However I’ve always checked to see if my treatments were covered before approving them. I never take anything for granted.

Bob
Posted 4/29/2018 11:22 PM (GMT 0)
This is just a general thank you to all who have responded so far. I'm on deadline with a project and can't even read through all the responses yet, let alone reply individually. Will do so in a couple of days.
--SP.
Posted 4/30/2018 1:17 PM (GMT 0)
Richard is that project golfing? LOL How many treatments do you have left?


Larry
Posted 4/30/2018 1:57 PM (GMT 0)
Break60,

I am on the exact same plan and companies and have had the same very positive experience.
Posted 4/30/2018 2:45 PM (GMT 0)
Saipan
let me advise you on the internist bill. Write an appeal letter to your insurance company explaining that you went to in network hospital and used an in network surgeon, and the hospital chose their own internist and you had no opportunity to provide input as to what doctor, if any, needed to see you. It is key to state you had no input into the decision as to the choice of doctor.

you will likely get coverage at the network rate. I had the same thing occur with emergency surgery for appendicitis. In network hospital but the surgeon was out of network. In my appeal I told them I was in the emergency room bed at 11 pm and had no opportunity to shop around for surgeons. Blue Cross covered the full amount.

Teddy
Posted 5/1/2018 11:22 AM (GMT 0)
I'm baaaack.

No, Larry, the project wasn't golf. Work. Really. Alas.

3 putt: I think the lesson from your fusion and Prolaris and my Decipher experiences is: If it's likely to cost more than dinner at Appleby's, call your insurer and get either (1) pre-authorization or (2) confirmation that pre-authorization isn't needed.

Prato: Thanks for the advice re GenomeDx. I strongly suspect the surgeon's office has dealt with this already. I haven't received a bill from GenomeDx and don't think I will -- their relationship was with the surgeon, they sent the Decipher score to the surgeon, not to me. I'm wary of stirring the pot on a potential $5K bill. Strongly suspect that the surgeon has already negotiated this with GenomeDx. Otherwise the surgeon, who has a very efficient billing department, would have passed it along to me. Also, he's in the Florida Hospital system, and FH has confirmed that I have no outstanding bills with them.

Allen and teddy9: In light of your comments, I thinking about protesting the denial on the interist's fee. I certainly would have already if I'd gotten a bill. That's the trouble with getting an EOB but not a bill -- take action or not? If any of our members worked in the insurance biz, I'd like to hear from them.

Allen again: I take your point about patient responsibility. But I think you and I come down differently on how far that extends. While it's a fair point that I should have suspected that an Axumin wasn't strictly necessary -- I'd read a decent number of posts on it -- and should have recognized my share of the cost could be high, I don't know that it's fair to put that on most patients. A PCa patient goes to a top RO for a salvage consult, the RO says he wants pt to have an Axumin PET scan, pt calls imaging center, imaging center clears it with insurer and tells pt it's a $150 copay plus 25% of agent/supply, pt says Let's do it. Where did the patient fall down on the job? I'd put that on the RO and/or imaging center to warn the patient that the cost of the agent runs into the thousands instead of the typical few hundred dollars.

RobLee: I'd modify your Lesson #1 to: Even if your insurer denies pre-authorization, come to your own independent view of whether the test/procedure is necessary. If it is, and you can at all afford it, DO IT and then keep fighting with the insurer. I agree in full with your #2, which I read as: Never pay in advance, never pay more than you're billed for. I would add: before you go for any test/procedure, call your insurer and find out what responsibility will be. DO NOT depend on the clinic/hospital to get it right. The major imaging center on Guam overcharged me for a myriad of initial tests/procedures I had done in June/July 2017. I only found out about it when I went to pay a small bill for a later test. The finance staffer told me she was showing the center actually owed me $90 and they'd cut me a check. I don't know when if ever the center would have gotten around to this otherwise.

John_TX: Thank your lucky stars! Actually, except for the internist glitch, my surgery went similarly. BC/BS covered it beautifully. I was out of pocket $325 for the surgeon and hospital.

Break60: I look forward to my 65th birthday in 2021! Your simple lesson is worth repeating: Always check to see that treatments are covered before approving them.
Posted 5/1/2018 12:20 PM (GMT 0)
You do a number of things.

First make a direct appeal to the insurance company that you did not choose the internist. Be prepared to write directly to the chairman of the insurance company with copies to the state insurance commissioner, the state consumer advocate and a couple of local news casters that are consumer advocates.

Second you appeal to the hospital to eat the out of network cost as they imposed an out of network doc and did not give you any choice or voice in the matter. Again, know who the President or Administrator of the hospital is and write a letter with the appropriate copies going to all the people that the administrator does not want knowing about this.

Third, write directly to the state insurance commissioner and consumer advocate and copy the insurance company president, hospital administrator, and the various newscasters that have the loudest local voices on these matters.

Somewhere in all this you will get proper action. If the hospital takes legal action in any way for non-payment then you counter-sue immediately and make them spend money or withdraw the claim for payment.

90% of all this can be done in a very short period of time from your home computer nand a bit of website searching. Easy. Don't roll over.
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