Another Frustrating Infusion Center Visit

Since I was already maxed out with my out of pocket before I started Remicade I haven't signed up yet for Remistart. Since I get my meds through the hospital I'm not sure how that's going to work. With Entyvio, co-pay assistance was treated as secondary insurance for the med only and the hospital took care of everything and just billed me the $5. Insurance counted the full amount toward my out of pocket though.

If Remi is a credit card I'm not sure how the hospital will apply it. I will worry about that in January lol

Did you ask your insurance what other infusion centers are in your network?

My insurance person told me it didn't matter that the center is out-of-network since the nurse practitioner there is in-network. Is she wrong? There is no other infusion center close to me. Even that one is 45 minutes away.

Someone pays the cost one way or another. If that's by taxes, from net income, or someone else covering the bill for you. Research, medicine, doctors, facilities, overhead, equipment, disposables, utilities to power all those, it's all not cheap....

Also, huge thank you to whoever told me that stand-alone infusion centers are cheaper! You are going to save me $1,000 every year!

I'm not sure I understand. I'd have to pay $5,000. That's my out-of-pocket max.

Sara the billing is crazy complex on remicade. Did you get the official Explanation of Benefits from your insurance, as that's what matters most? Anything before that is irrelevant and guesses. Remistart/Jansen-Carepath will pickup the costs associated with the J-code for your medication, J1745. Often they pay the deductible/copay when there's multiple things billed and one deductible/copay listed. They will not pay for the infusion code 96413 and 96415 for the IV infusion itself.

Yes, remistart/carepath is like a secondary insurance when setup to automatically and electronically process at your infusion center.

Keep in mind that the hospital can only quote you the "Billed amount" not the "Insurance Allows amount," an important distinction. Anything before the EOB is all smoke and mirrors, and anybody's guess.

1.) Hospital initially says I want X-unreasonable amount for these services.
2.) Insurance says, we only allow Y-amount for this treatment, and insurance pays Z-amount, and patient pays ABC amount. Jansen Carepath/Remistart only cares about ABC patient owed amount.

The difference between X-UnreasonableAmount, and Y-insuranceAllowedAmount is astounding, often $20,000.00 versus $10,000.00 for those amounts, to spit-ball them with easy remicade numbers. Same applies for infusion charges, I'd expect the Y-insuranceAllowedAmount to be roughly half of X-UnreasonableAmount.

Deductables and copays are hard to predict in how they would be rebated. Remembered having a flat $1,500 yearly delectable, having a remicade infusion in January and remistart paying all of that for me. No deductible for any hospital inpatient, or outpatient services for the remiander of that calendar year. Yay, no deductible for colonoscopy or whatever else I needed that year.

Yeah % of service cost is a bummer. Arrange to use the insurance's preferred mail-order specialty pharmacy for future infusions. I've been mandated to use Accredo, CVSCaremark, and other specialty pharmacies in the past due to insurance requirements. My infusion center had a nurse who set that up, as soon as I was surprised by the billing. Thereafter it was simple, and automatic for all remaining infusions.

My deductible is $350. Was met many moons ago. My co-pay for Remicade is a flat $200...that doesn't depend on what the insurance "allows" the hospital, or in this case, the pharmacy, to charge for Remicade. I understand it affects my co-insurance amount for my actual infusions, but I already got my bill, so I know the exact charge... Maybe I'm misunderstanding what you're saying?

I've spent hours calling all of these places and they all tell me Janssen doesn't pay for the infusions, so there's nothing else I can do.

Are you saying you don't have co-pays or coinsurance under your insurance plan? You're saying all you have is a deductible and then everything's free? I've never heard of that.

Janssen Carepath pays for my co-pay for Remicade (the actual medicine, not the infusion), which is a flat $200. I pay $5 of that. I have co-pays for medication and coinsurance (of 15% for in-network providers) for hospital stuff, labs, the infusion, etc. I posted several times in a row (sorry), so you may have missed the post explaining all of this.

Ok, so you do have to pay $100 then. I have BCBS Federal. Interesting to see your EOB, thanks. Every infusion I've had, I've been there almost 4 hours, mostly due to the nurses having to poke me so many times, so that's great they bill us by the hour. And now I'm even more confused why it's all there together. Whatever, I'll just pay what they bill me. I'm over trying to figure this out.

Yeah sorry, so many numbers and math was never my strong point (you should see my college and highschool grades in it)! Confusing on a number of levels when talking insurances and bills for sure!

iPoop said...
Yeah sorry, so many numbers and math was never my strong point (you should see my college and highschool grades in it)! Confusing on a number of levels when talking insurances and bills for sure!

Same here, lol. Makes my brain hurt. Thanks for trying to help me...think I may be beyond help. haha. jk.