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Remicade BCBS pre authorization required with Medicare

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Posted 4/9/2024 5:42 AM (GMT 0)
Doctors Medical necessity letters were emailed to me, my husband's workplace appeals office, insurance commissioner, senators and BCBS this morning.

BCBS has decided to keep me on Remicade and to approve it for 12 months. They have flagged my account for next year to leave me on Remicade and to approve with just the letters. (I'll believe that when it happens)

One of the doctors handling escalated approval/denial issues called me this afternoon. He apologized, but then sort of chided me about not going thru BCBS appeal process. I had to educate him about Remicade, antibodies and the inability to use Remicade if you miss scheduled doses. (I don't think he was a GI) Then he did ask me why someone would keep such detailed notes from so many doctors and the scheduling/visits for such a long time. DUH...

I should get my official letter in 7 to 10 days. BCBS did a group email to all the doctors and cc'd me.

Infusion scheduled for Thursday.

Thank you all for your kind words of wisdom and support.

Clo
Posted 4/10/2024 12:16 AM (GMT 0)
That's good news, Clo! Your infusion will only be a week late so you should be fine. Sounds like that doc got scared when he was bombed with all those letters and thought be better try to make nice to you. Glad this has been resolved, Now you can breathe <3
Posted 4/10/2024 9:18 PM (GMT 0)
Thanks again all. I was so stressed I didn't know if I was coming or going.

Medicare is pretty straight forward. It's the secondary BCBS that's had me jumping thru hoops. I brought up that pre-approval line that was in the brochure to my infusion clinic last year--preparing for 2024. They said they didn't have to do that because it was part A. Now we have discovered that wasn't correct.

BCBS told the infusion clinic they would be doing an audit on the BCBS accounts and if pre-approval was not obtained then BCBS is going to ask for their monies back--because now the infusion place knows that they have to obtain pre-approval. I was just the first one they came across.... So their billing department is checking into it so others won't have huge bills due...

BCBS paid for my January office visit portion but did not finish paying for the meds. They did pay the February infusion... Meds and all. We are still appealing the January decision and hope that one will be paid.. But my infusion place is considering having Medicare patients sign an ABN????

What's an ABN?. Anyone have to do that? Should I sign it if they ask me to tomorrow?

Clo
Posted 4/10/2024 9:41 PM (GMT 0)
https://www.medicareinteractive.org/get-answers/medicare-denials-and-appeals/original-medicare-appeals/advance-beneficiary-notice-abn

It's basically saying that you will pay if medicare (or in your case BCBS) doesn't. If you don't sign, they probably won't give you the infusion. Since you have the PA now it's shouldn't be a worry.
Posted 4/11/2024 3:04 PM (GMT 0)
You should have told the insurance guy that you keep detailed notes for cases like this when insurance is trying to screw you over and hoping you’ll just crawl away and disappear. 😈 well that was a week + of stress you didn’t need! So sorry! But glad you warned us all of the underhanded tactics. I think it reprehensible that they try to enforce fine print crap mid year right at the point where you need a treatment. Now I’m worried that this will extend to other plans. I worry because I know Medicare and my supplement are losing $$ big time on my treatments.
Posted 4/11/2024 5:54 PM (GMT 0)
They really are losing money, and I guess I can understand wanting to do a pre approval..... But..

If they are going to do a pre-approval then insurance companies should be obligated to notify customers that were with them the previous year at least 90 days before and let them know it's applicable to them---even if they are a secondary insurance.

Insurance is getting sorta shifty.... They send out those letters that say you have to "opt out" of something or they will change your coverage..... That's how they handled the Medicare Pharmacy plan they tried to get everyone to go into. Sneaky! If you didn't "opt out" they were changing your pharmacy benefits from BCBS (a commercial plan that's supposedly meeting the Medicare standards) to only Medicare. So you'd have a deductable to meet.... While now it's 80/20.... But pre-approval is required for some high cost drugs.

They didn't make me sign the ABN this time.... Lol. I think they forgot. I'll deal with it when it happens.

Thanks again guys. My Remicade pre approval line was actually in the back portion of our brochure... it does state "Specialty Pharmacy" but lower down they added a little verbage to cover themselves as a secondary payer. So double check those brochures..

Clo
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