Hi all! Well LJ has had a much better year than the first 2 years with this wretched disease, but has never remotely been close to remission. When we moved his care to CHOP a year ago they really got him turned around. So they ordered a FC for the first time ever & it came back at 750. Not great news but the Dr said in 2 months we are going to re-check along with Humira levels and all the labs. In the meantime we get a bill for $527 saying FC is not cover. Then hubby called the ins co & they said it's never covered because it's not a reliable test. Has anybody ever had this happen?
FC help !?!
- Thread starter Gmama
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Ours used to be covered but suddenly was experimental (??)
As of Jan of this year
You would need your doctor's office help to appeal it
As of Jan of this year
You would need your doctor's office help to appeal it
Maya, we were in a hot mess with LJ before CHOP. I was so thankful they were willing to take over his care! He is still not in a full remission but is 100% better than he was if that makes sense??
Thanks for the reply to you & Mr chicken!
Thanks for the reply to you & Mr chicken!
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CCFA has a sample appeal letter for FC. Don't know if that would help since we've never had to appeal. Our insurance gave us a hard time with the pill cam, but our GI's office was able to talk to them and get it covered.
Glad LJ is better!! Is he on weekly Humira or every other week? We found switching Humira to every week made a big difference to my daughter.
Glad LJ is better!! Is he on weekly Humira or every other week? We found switching Humira to every week made a big difference to my daughter.
He is on weekly Humira & I feel like he gets a lot out of the MTX as well.
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Our insurance does not cover it either.... so frustrating. It is just like a CBC, liver enzyme or any other test to check levels.
I think all the GI;s in the nation need to send off letters to the insurance companies to tell why the FC is important and prevents extra colonoscopies. The GI that represents the Insurance company speaks for all of them???? ARGGG. I wrote letters, made calls to the insurance company and sent in the doctors letter.. but in the end they took the recommendation of this one doctor.
I am so sorry that you are stuck with that bill. NOT FAIR!!
I think all the GI;s in the nation need to send off letters to the insurance companies to tell why the FC is important and prevents extra colonoscopies. The GI that represents the Insurance company speaks for all of them???? ARGGG. I wrote letters, made calls to the insurance company and sent in the doctors letter.. but in the end they took the recommendation of this one doctor.
I am so sorry that you are stuck with that bill. NOT FAIR!!
DustyKat
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So fab to hear your lad is doing well Gmama :ghug: and I hope that the repeat FC in a couple off months time reflects that. Good Luck!
I also hope you can the coverage of the test sorted and soon. For the life of me I can’t understand how they can charge $527 for a FC! They aren’t covered in Australia under our Medicare system but I only paid $50 AUD ($36 US) and I think Catherine pays $40 AUD??
Lord knows where they get $527 from, what a rip off. :ymad:
Dusty. xxx
I also hope you can the coverage of the test sorted and soon. For the life of me I can’t understand how they can charge $527 for a FC! They aren’t covered in Australia under our Medicare system but I only paid $50 AUD ($36 US) and I think Catherine pays $40 AUD??
Lord knows where they get $527 from, what a rip off. :ymad:
Dusty. xxx
Catherine
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Thanks gals! I have a call into the dr to see what or if they can suggest to get this covered (or at least reduced) before we do the next test. I'll keep you posted on what pans out.
Thanks again for the replies!
Thanks again for the replies!
You are not a grump at all. Until now, he has been in a hot mess so we never had the test done before. His CRP IS 2, not perfect but much better than it has ever been. He grew an inch from April til June, gained 3 pounds, also felt so good he joined the track team (so gained while doing lots of running) and he physically looks much better. All of that being said, when the FC results were 750 they were asking if he was sick at all, saying he could have had a mild something without knowing it, blah blah blah. So they said to repeat it because lots of thing can throw the results off. So we said ok, having no idea it wasn't covered.
crohnsinct
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Hey there...sorry was away at swim meet all weekend.
First question...who did the test? Was it a lab or the hospital? That rate is highway robbery. The highest lab rate I have been quoted is $240. The lowest is $118 from Clinical Labs. I live in CT so not that much diiferent than PA so I don't know how they can justify that cost.
The hysterical part is the insurance negotiated rate is about $18! You will not get a lab to write down the bill unless you are uninsured. Oh, I tried...I said for all intents and purposes I am not covered for this test and they said no...you have to be totally and completely uninsured.
If your test was done at a hospital, you will have an easier time getting the bill written down. But FIRST appeal to the insurance company.
I have two appeals going (two daughter's) and the doctor has a third appeal. Do not use the CCFA appeal letter. Sorry, they are an excellent resource and great organization but that appeal letter is for garbage and no insurance company will reverse their decision based on that letter. You can use it for framing your letter but you have to be VERY specific as to your son's personal circumstances and why it is a necessary and useful tool. You also need to get a copy of the insurance company's clinical policy bulletin (they have numbers) and see why it is they do not cover it. If you can't negotiate their website (they hide these things) it is just as easy to call member services and ask them why it was denied and what bulletin the denial is based on. They will give you the number and then you can find it on the website.
I am sure it is the same as my company's policy...they cover it for diagnostic reasons to screen people not needing scopes (ie: probable IBS patients)..of course they agree it is a great screening tool... it saves them money! However, as a clinical disease management tool, they say the evidence in the studies does not support it. If you read their clinical policy bulletin they will reference studies and based on those studies they are right. The hard part is then you have to find studies that refute theirs. Most studies say, "FC appears to be a good tool to manage disease" or "there is evidence that...." But very few come out and say point blank, "FC IS THE TOOL". What also helps is if you can find some management guidelines to GI's..ie: CCFA, Professional Society's etc...something that says, we suggest you use this tool...so far there isn't anything. I have my GI helping me with finding anything that will accomplish these goals and what he has sent hasn't helped.
Your last recourse is to show why FC for your specific case is needed. For my daughter, her inflammation doesn't show in her bloods and she is pretty asymptomatic. So we do not know the Crohn's is flaring or heading into a flare until she is pretty bad. So we are now appealing on that basis...That managing with blood markers and symptoms alone leaves her unprotected and at risk of hospitalization or surgery which will cost them thousands more..so far DENIED. We are bringing that to second appeal now.
O has also had a test recently and she is doing great, scopes were pristine. Just inflammation in the biopsies. There is no way I will get the insurance company to reverse that denial. However, I agree with the person above, we all have to appeal and send those letters and supporting studies etc otherwise we are letting them get away with making poor clinical decisions that will leave many people unprotected.
Oh and the best part is when I spoke with someone on the phone about our first denial and what more I could give them she said and I quote, "well all the insurance companies have the same policy...you will have a hard time getting this approved if no other insurance company covers it". My response, "Really? Because I am pretty sure what you are hinting at is collusion!"
Ugh! 8 in the a.m. and I already want to bite someone's face off!
On a positive note..so glad he is doing much better! Super stoked about the track!
First question...who did the test? Was it a lab or the hospital? That rate is highway robbery. The highest lab rate I have been quoted is $240. The lowest is $118 from Clinical Labs. I live in CT so not that much diiferent than PA so I don't know how they can justify that cost.
The hysterical part is the insurance negotiated rate is about $18! You will not get a lab to write down the bill unless you are uninsured. Oh, I tried...I said for all intents and purposes I am not covered for this test and they said no...you have to be totally and completely uninsured.
If your test was done at a hospital, you will have an easier time getting the bill written down. But FIRST appeal to the insurance company.
I have two appeals going (two daughter's) and the doctor has a third appeal. Do not use the CCFA appeal letter. Sorry, they are an excellent resource and great organization but that appeal letter is for garbage and no insurance company will reverse their decision based on that letter. You can use it for framing your letter but you have to be VERY specific as to your son's personal circumstances and why it is a necessary and useful tool. You also need to get a copy of the insurance company's clinical policy bulletin (they have numbers) and see why it is they do not cover it. If you can't negotiate their website (they hide these things) it is just as easy to call member services and ask them why it was denied and what bulletin the denial is based on. They will give you the number and then you can find it on the website.
I am sure it is the same as my company's policy...they cover it for diagnostic reasons to screen people not needing scopes (ie: probable IBS patients)..of course they agree it is a great screening tool... it saves them money! However, as a clinical disease management tool, they say the evidence in the studies does not support it. If you read their clinical policy bulletin they will reference studies and based on those studies they are right. The hard part is then you have to find studies that refute theirs. Most studies say, "FC appears to be a good tool to manage disease" or "there is evidence that...." But very few come out and say point blank, "FC IS THE TOOL". What also helps is if you can find some management guidelines to GI's..ie: CCFA, Professional Society's etc...something that says, we suggest you use this tool...so far there isn't anything. I have my GI helping me with finding anything that will accomplish these goals and what he has sent hasn't helped.
Your last recourse is to show why FC for your specific case is needed. For my daughter, her inflammation doesn't show in her bloods and she is pretty asymptomatic. So we do not know the Crohn's is flaring or heading into a flare until she is pretty bad. So we are now appealing on that basis...That managing with blood markers and symptoms alone leaves her unprotected and at risk of hospitalization or surgery which will cost them thousands more..so far DENIED. We are bringing that to second appeal now.
O has also had a test recently and she is doing great, scopes were pristine. Just inflammation in the biopsies. There is no way I will get the insurance company to reverse that denial. However, I agree with the person above, we all have to appeal and send those letters and supporting studies etc otherwise we are letting them get away with making poor clinical decisions that will leave many people unprotected.
Oh and the best part is when I spoke with someone on the phone about our first denial and what more I could give them she said and I quote, "well all the insurance companies have the same policy...you will have a hard time getting this approved if no other insurance company covers it". My response, "Really? Because I am pretty sure what you are hinting at is collusion!"
Ugh! 8 in the a.m. and I already want to bite someone's face off!
On a positive note..so glad he is doing much better! Super stoked about the track!
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Very glad he is doing better! That really stinks about the FC. I would start by having the doctors office call the insurance and explain why it is a necessary test.
CIC ...you are amazing! Thanks for the response. We are still going round & round with it all, I will keep you posted with what we work out. Just another thing that is nuts about this stupid disease:ybatty:
this story is quite surprising to me. My GI has told me FC is a ridiculously inexpensive test, like 40$. in canada the gvmt pays for it. hoping you find an arrangement for that.
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