Advocating with insurance and hospital to cover cost of BCG

3 months 2 weeks ago #60698 by RosieF
My boyfriend went through his 6 BCG treatments, during a very, very stressful time, for reasons unrelated to his cancer. He did really well with the treatments though we haven't had the next scope. That will be at the end of this month.

We went to a hospital that accepts his aca plan, as does his urologist. But we just found out that none of the BCG treatments were  covered under his insurance which I simply cannot understand. We assumed, being in network with his doc and hospital, that these would be covered. It looks like the hospital may have given us some kind of discount.

Naturally, we want to challenge this, and get financial assistance if we can. Does anyone here have information that can help about how to contest this kind of thing? And does anyone have any experience with ACA policies that might be a little more complete in coverage? We've been really happy with this aca silver plan up till now. But we don't know that his BCG treatments are over yet. And it is really scary to think we will need to pay for these treatments each time he needs thm.

Thanks for any help.

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3 months 2 weeks ago #60699 by Alan
I don't have a lot of experience with insurance complaints but, here is a start and something you can do on your own. I would start with the hospital administration, whoever wrote your insurance policy, adding complaints to the state board of insurance, possibly your state's attorney general office, and your local papers ombudsman (troubleshooter). It often will take a month or more to get some kind of response which hopefully will clear you to have the BCG covered. Being a standard procedure I do not understand why it is not covered.

DX 5/6/2008 TAG3 papillary tumor .5 CM in size. 2 TURBS followed by 6 instillations of BCG weekly with a second round of 6 after a 6 week wait.
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3 months 2 weeks ago #60700 by RosieF
I know, it really shocked us, not to mention the hospital is usually really thorough about letting us know what we need to pay in advance. For sure we will follow this up. But we may need to pay in order to keep seeing the hospital so will do whatever is necessary

Hard enough to fight the cancer when you have to fight your insurance too, especially for something basic like this.

Thank you. 

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3 months 2 weeks ago #60701 by Jack R
RosieF,

Hospital and Outpatient Center billings and insurance coverage issues are a frequent issue. Asking the price of a procedure in advance, and having the doctor or clinic determine the amount insurance will pay and what will be due from the patient is a standard practice. Questions and issues arise even so.

Dealing with unexpected medical bills is best handled with a cool, calm,  friendly approach to both the provider and the insurer.  

The AARP produced a great (in my opinion) article on dealing with such surprises. It is found at:

www.aarp.org/money/credit-loans-debt/info-2019/dispute-medical-bills.html

If you are new to medical insurance, or the specific insurance, you will want to know and understand how the policy handles co-pays, deductibles, stop loss (or out of pocket maximum) amount provisions, and any pharmacy deductibles (BCG might be billed as a pharmacy item). You will want to know if a "series of 6 BCG treatments" will require one or six co-payments or deductible payments.

Hopefully, there has been an error in billing, or a misunderstand of the charges by insurance. If not, after taking all the steps recommended in the AARP article,  you can always try to negotiate the balance due.

Good luck,
Jack 


6/2015 HG Papillary & CIS
3 Years and 30 BCG/BCG+Inf
Tis CIS comes back.
BC clear as of 5/17 !
RCC found in my one & only kidney 10/17
Begin Chemo; Cisplatin and Gemzar
8/18 begin Chemo# 3
Begin year 4 with cis
2/19 Chemo #4
9/19 NED again :)
1/2020 CIS is back
Tried Keytruda, stopped by side effects
Workin on a new plan for 2021
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3 months 2 weeks ago #60702 by Alan
As Jack said calmness is the best procedure as the powers to be are not trying to be personal. Although they are also protecting their business interests. One last addition. Many times a billing error is a coding issue. Perhaps your BCG issue may fall into that category.

At the same time, I still wouldn't hesitate if stonewalled to complain to the state board and AG. Insurance companies hate complaints to those entities.

DX 5/6/2008 TAG3 papillary tumor .5 CM in size. 2 TURBS followed by 6 instillations of BCG weekly with a second round of 6 after a 6 week wait.
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3 months 2 weeks ago #60704 by dtat60
As Alan stated, sometimes it can be a coding issue. From your original post you mentioned ACA so I assume that your boyfriend is not on Medicare or a subset (advantage or supplement) so not sure if the following would apply. Or if non-Medicare coding is the same? However, I pulled up a EOB from one of my BCG maintenance does and it showed the following. I do know that for Medicare patients the insurance company pays without prior approval for specific CPT codes and others require prior approval or will not pay otherwise. 

Hopefully in your case it is a coding issue......see attachment.

08/16 Blood in Urine;09/16 CT Scan, RPG, Cysto;10/16 TURBT;12/08 BL TURBT;01/17 6X BCG;05/17 NED, 3X BCG, 9/17 NED, 3X BCG,1/18 NED, 3X BCG,7/18 NED, 3X BCG
Attachments:
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