Prometheus Testing for Remicade levels/Antibodies

[crohnsinct]

Hi gang! I posted in some one's thread what I found out but now have more info and thought I would give it it's own thread.

Prometheus Remi Levels/antibodies test cost $2,500.

As we all know many insurance companies don't cover it.

I called Prometheus and here is what I found out. If your company flat out denies the claim they will appeal on your behalf. They will appeal as many times as necessary to exhaust the appeals process. If they exhaust the appeals process and the claim is still denied then you will be billed only $250.

Here is the hitch! If you insurance company agrees to cover but at a reduced rate then you are on the hook for whatever your patient portion in your plan is. Prometheus is an out of network lab for most insurers. It is possible that they will agree to cover and agree to the $2,500 BUT keep in mind you will have to meet your out of network deductible before they kick in and then also have to pay the coinsurance percentage of anything left.

So for example...our in network deductible is $500. Our OON deductible is $1,500. All of our providers are in network. O is having a good year (no hospitalizations etc that would bring us to our out of pocket maxs of $3,000/$6,000). We have met our in network deductible of $500 so we have $1,000 left on our OON (our insurance applies in network deductibles to oon).

Lucky us...Our insurance has agreed to cover the test at $2,000. So we pay $1,000 to fulfill our OON deductible and 30% of the remaining $500. It would have been better if they kept denying the test:/

The procedure code is unlisted so it is not a simple call to see if insurance will cover it. If you are considering the test and you want to know how much you will be on the hook for send in all the documentation way ahead of time to get the insurance companies decision. This includes Prometheus propaganda and your doctor's explanation of why it is medically necessary etc.

Good Luck!

 

[crohnsinct]

Forgot to mention...they do have an income based assistance program to help with the cost as well. Also, will set up a payment plan.

 

[Jmrogers4]

Thanks! I know Jack's GI has talked about this test. I will make sure I get everything done beforehand.

 

[crohnsinct]

Hey gang! Sorry I haven't been around much. Just wanted to update some Prometheus info...O's doc is talking about running the Prometheus Levels/Antibodies test again...My first thought was ugh...Another $2,500 bill, appeals (which thankfully Prometheus totally handles for you) etc. So I called Prometheus and it turns out that the $2,500 charge is just for the first test. The second test is only $375. The charge is still subject to insurance approval and all but a lot more palatable than the $2,500. Sorry I was so excited that it is only $375 I forgot to ask how much we would be on the hook for if all appeals were exhausted and insurance still denied...I am sure not the full $375. I did however ask if that was second test in calendar year and the rep said no once the first test is run subsequent tests are billed at a lessor rate...I don't have that in writing though.

 

[crohnsinct]

At O's appointment with GI today he mentioned that the hospital is in talks with Labcorp regarding a test they have which seems to be just as good as the Prometheus test for testing Remicade levels and antibodies but only costs $500. Just though I would pass that along for those of you for which the $2,500 charge is a bit steep...if you don't have a problem with that charge, wanna adopt me? :ycool:

 

[xeridea]

As I understand it, the Prometheus tests are more sensitive than other labs' tests. They are also 4X - 5X more expensive. So perhaps for regular monitoring the less sensitive tests can give sufficient information for gauging dosing levels and intervals, and then Prometheus can be used when trying to assess loss of response.

Beside what crohnsinct suggests with Labcorp, Mayo Medical Labs and ARUP Labs offer the less sensitive ECLIA tests. Talk to your GI about the test differences and if appropriate for your case.

Also, for what its worth, Nestle acquired Prometheus in 2011 for an estimated $1B as part of its expansion strategy in clinical nutrition services related to digestive disorders.

 

[Mehita]

Okay, so I just got a $2250 bill from Prometheus today. It was $2500 and listed $250 maximum OOP from Blue Cross Blue Shield. Based on what you said in your first post, I'm stuck with the $2250, right?

We will try the assistance plan they offer, but I don't think we'll qualify.

On top of this test from May of 2015, DS' GI ordered another one in Feb of 2016. That one should be $375?

This is so frustrating.

 

[Jmrogers4]

Just got the bill for us with Regence blue shield denying it for $2500 saying it was experimental. When I had talked to Prometheus they said even based on our income it would about $275 or $375 can't quite remember but I know it was way better than $2500. They try and get insurance to pay for it but they do the fighting for you. Now I just have to find the phone number they gave me and figure out what the next step is.

 

[my little penguin]

Just call prpmethiues billing dept
They will help you straighten it out
We paid very little after calling the billing dept.

 

[Mehita]

I'll call in a bit, but I think we're stuck because of CIC's "Here's the hitch..." comment. It looks like BCBS did pay $250.

"We have exhausted our billing efforts with your insurance company. The balance remaining is your responsibility".

Does anyone know what their income guidelines are?

 

[malorymug]

I'm in the middle of this as well. Prometheus is very nice. My understanding is if your family income is less than $125,000, the max you will pay is $250.00. You will need to apply/fill out a form.

 

[Mehita]

Last page has the income guidelines:

http://www.anserifx.com/PDF/Insurance-Financial-Support.pdf

I just called and am personally not happy with the answer, since we fall under "the hitch" that CIC talked about and do not qualify for financial assistance.

They did confirm that future tests will only (pfft!) be $375 and she said they already have the February test in the works at that price.

 

[Mehita]

Oh my, oh my, oh my!! They just called back and said the adjustment is supposed to be $2250 (not $250) and we only need to pay $250! I couldn't help myself and starting crying on the phone. We are just swamped with all the beginning of the year medical bills right now and I'm so overwhelmed. Finally, some hope!

 

[crohnsinct]

YAY! So glad it worked out. The people at Prometheus are so nice!

The hitch only comes in if your insurance covers the test. It sounds like yours did not cover the test as the Prometheus bill says max OOP $250. That is their policy not the insurance. Insurance will just either cover or not and then let the co pays determine how much you are on the hook for.

Can I say WOW! They processed that may 2015 appeal pretty quickly. We just had our external review for a test run in 2014! Our insurance is no longer covering the test at all so luckily we fall into the $250 max as well.

 

[Jmrogers4]

When I got home yesterday, there was a letter from prometheus aksing for the EOB so they could do their magic

 

[CrohnsDadNJ]

Our GI's office sent usual documents and Prometheus propaganda for Anser IFX to the insurance company for medical review. Lets see, fingers crossed


I spoke to Prometheus billing department and we MAY qualify for the $250 cap if insurance does not cover.

How often do your kids usually have to have the test? If its $250 a year, we may be able to swallow the costs, but if its more often the costs add up fast.

I would also love to hear stories of successful appeals.

 

[my little penguin]

First time ours was approved no issues

BUT
We had it drawn at the hospital lab- the hospital lab is in network so if they decide to send it out then it's their cost as to where
Second time Prometheus changed abd wanted only their own service to draw the blood
We assume it was approved since it had been the time before
Nope
Since Prometheus drew the blood it was out of network
Appealed by Prometheus
And it was covered eventually not by our primary insurance they still rejected it
But secondary insurance

 

[crohnsinct]

As long as your insurance totally and completely denies the claim and Prometheus exhausts all appeals (including external review) it is currently Prometheus's policy to bill $250 max. That amount could be less if you qualify.

Usually, patients do need their levels tested more than once a year or so. My daughter has actually now gone years without a test. Once your GI establishes that your son's level is right and working, they will only test if there is reason...usually because what appear to be symptoms are cropping up or allergic reaction or you are requesting to de escalate dosing and such.

I don't think all tests would be $250 because every test after the first is billed to the insurance company at $375 so once denied and exhausted appeals they will probably adjust that also.

Our first test was approved but as you see in my first post here that is not always a good thing. Approval at an out of network lab and at a reduced rate leaves you on the hook for more of the bill.

Our second test was denied all the way through external review. I guess our insurance company changed their position. So we will see how much I get billed.

 

[CrohnsDadNJ]

Thanks for the responses. We usually hit our out of pocket max for the year so we are better off if insurance approves. Else this cost will be on top of OOP max.

We intend to do the test at our in network hospital outpatient lab/infusion center which has a relationship with Prometheus, so the insurance will be billed by hospital. If insurance does not cover, Prometheus said we are on the hook for $250 per test, even for the subsequent tests. It sounds crazy, because the first test is billed at $2500 and subsequent tests at $375. But so much of our healthcare economics does not make sense I have learnt to suspend logic...

 

[Madhu]

We usually hit our out of pocket max for the year so we are better off if insurance approves. Else this cost will be on top of OOP max.

We hit our OOP max last year and were billed $250 by Prometheus. Yup its a pain. As you say, I hope it is not a very frequent testing.

 

[CrohnsDadNJ]

So bad news from insurance. The CPT code provided by Prometheus is 84999. It shows up as "Unspecified Chemistry Procedure" in a google search, but as a genetic test in insurer's internal database. Therefore, they sent a pre approval packet to the GI's office with information on why a genetic test is needed. Obviously its going around in circles when we say its not a genetic test. Does anybody use a different CPT code?

On somewhat better news, CPT codes 80299 and 82397 are covered procedures. These seem to be Labcorp exclusive test but Labcorp is out of network for us, so we are trying to figure out if the hospital outpatient department can do the billing. The GI's office said its OK to use those tests for now and we can discuss Prometheus if required later. Does anybody have experience with these tests? The first code is to test levels of infliximab, the second one tests for antibodies.

 

[my little penguin]

The Prometheus test is a genetic test
It checks for nod2 etc....
The other tests at Prometheus are used to check remicade levels and antibodies so that might be the confusion

 

[my little penguin]

http://www.prometheuslabs.com/resources/ibddiagnostic/ibdsgi-productdetaildx13005-0113.pdf

The genetic testing codes used

 

[crohnsinct]

Our GI had told us about Labcorp's test and at the time it was only $500 as compared to Prometheus testing at $2,500. He said he would be fine with using the labcorp test but as they were out of network for us and Prometheus adjusted the bill down to $250 we stuck with Prometheus.

 

[CrohnsDadNJ]

The Prometheus test is a genetic test
It checks for nod2 etc....
The other tests at Prometheus are used to check remicade levels and antibodies so that might be the confusion

Yes, the test ordered by the GI is to check for Remicade levels and antibodies. I have been in this frustrating loop for a while now - (1) Prometheus says 84999 is the only CPT code they use, (2) insurance says 84999 is for genetic testing and preauthorization materials are sent for genetic testing (3) we respond that its not a genetic test, (4) Back to step 1.

Prometheus has an arrangement with the hospital we use to have the hospital do the billing, so its going to be in network. If we can get pre-authorized.

The problem with Labcorp is its not in network, and while in-network hospital lab will draw the blood, they do not have an arrangement with Labcorp to bill directly. So while 80299 and 82397 are approved CPT codes, there is no real way to use those tests.

At this point, the only options seem to be pay $500 (2x) or $750 (3x) per year with the Prometheus Links program, which I hate because we already hit max OOP.

Well at least the good news is S' calprotectin came back. Less than 15! First normal result is nearly a year!

 

[crohnsinct]

Prometheus only bills the first test at $2,500 with a write down to $250. All subsequent tests are billed at $350 full price. I imagine they will adjust those down as well. Our subsequent testing is still in appeals so I will let you know what it is adjusted to.

Also, you may find that as your son does well and his biomarkers are returning well and you are getting good levels/antibody results, the doc won't do them very frequently. We did them a lot at the beginning because of symptoms but once we found a dose and schedule that worked we do them maybe once a year.

 

[CrohnsDadNJ]

Yes, the test ordered by the GI is to check for Remicade levels and antibodies. I have been in this frustrating loop for a while now - (1) Prometheus says 84999 is the only CPT code they use, (2) insurance says 84999 is for genetic testing and preauthorization materials are sent for genetic testing (3) we respond that its not a genetic test, (4) Back to step 1.

Prometheus has an arrangement with the hospital we use to have the hospital do the billing, so its going to be in network. If we can get pre-authorized.

The problem with Labcorp is its not in network, and while in-network hospital lab will draw the blood, they do not have an arrangement with Labcorp to bill directly. So while 80299 and 82397 are approved CPT codes, there is no real way to use those tests.

At this point, the only options seem to be pay $500 (2x) or $750 (3x) per year with the Prometheus Links program, which I hate because we already hit max OOP.

Well at least the good news is S' calprotectin came back. Less than 15! First normal result is nearly a year!

OK, I have good news, I think. Our insurance uses Quest as the exclusive in network lab with zero copays. Just days before S was supposed to be tested for antibodies and levels, Quest informed the GI's office they now do such tests. So doctor wrote up a script for Quest, and results came back last week. Lo and behold, the results are from Prometheus! I panicked and called the doctors office if they made a mistake and wrote a script by mistake to Prometheus. Nope, Quest has its own CPT codes, processes the charges and outsources to Prometheus. So zero copay! Woo hoo!

 

[mish2575]

Ugh, I feel your pain. Took me over a year to straighten my bill out.

 

[malorymug]

Great news CrohnsDadNJ! Quest would be a great option here too. I know the docs are pushing really hard to get these tests covered by insurance. In the long run, Prometheus is cheaper than the incorrect dosage of Remicade.