Advocating with insurance and hospital to cover cost of BCG

6 months 2 weeks ago #60758 by RosieF
For some reason, I didn't get alerts on this so thanking everyone now for your responses. I did read the first two but after that didn't see them and am not on the forum regularly.
It appears that the hospital billed the charges through out of network PA's. We are not sure why as the dr who ordered the procedure is within network. We are following this up now and hope for a good outcome as the procedures did have prior approval from primary care and insurance.

We have heard billing through out of network providers is a common issue with hospitals, and I've been told by one person that UHealth, Miami is particularly bad about this. Can't verify how widespread it is, but know it is true in this case. So hopefully if they send charges through again under the doctor who ordered them, this will all be handled.

Thanks again.

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7 months 2 weeks ago #60705 by joea73
About the insurance/ACA on BCG treatment, you may try to contact the Merck National Service Center at 1-800-672-6372 from 8:00 AM to 7:00 PM EST.   FYI,  Product Onco-Tice  -  BCG for Bladder Cancer Treatment

Also, MERCK seems to have a patients assistant program.    www.merckhelps.com/    1-800-727-540

The pop up says -
During this unprecedented time, if you have lost your job and health insurance due to the COVID-19 pandemic and need help paying for your Merck medicines, the Merck Patient Assistance Program may be able to provide your Merck medicines at no cost.
Call 1-800-727-5400

Best

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7 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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7 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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7 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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7 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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