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Crohn's Disease Forum » Treatment » Remicade/Infliximab » Prometheus - What has your insurance paid for the test?


01-08-2016, 09:48 PM   #1
Jane
 
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Prometheus - What has your insurance paid for the test?

Hi all -

If you had the Prometheus Anser IFX test done and health insurance paid for the Prometheus Anser IFX test, can you share with me what amount your health insurance paid?

I had the Anser IFX test done. Prometheus charged my health insurance $2,500. Since my health insurance, Independence Blue Cross (IBX) does not have a contract with Prometheus, IBX and Prometheus do not have an agreed upon amount that IBX will pay for that test. IBX decided that the "allowable amount" for the test was $1,250.

I have a Preferred Provider Organization health plan. Since, Prometheus is out-of-network, IBX paid 70% of the out of network charges ($875) and told me that I am responsible for the other 30% ($375) of the "allowable amount."

I paid $375, but Prometheus is still billing me for the remainder of the balance ($1250).

The original $2500 is the gross charge for this blood test. Insurance companies never pay the full gross charge (for this blood test or any other blood test, hospital charge, physician charge, etc.). When they have a contract with a lab/hospital/physician, they negotiate an "allowable amount."

If Prometheus and IBX had a contract, and together, set the "allowable amount", Prometheus would not be billing me for the remainder of the balance. Since they don't have a contract, Prometheus is billing me for the full amount and they are allowed to do that.

I'd like to negotiate with Prometheus. I'd like to know what amount Promethus typically receives from other health insurance companies. If your health insurance paid part/all of the bill from Prometheus, what is the "allowable amount" that your health insurance decided for this test? What did your health insurance pay?

Any information that you can share with me would be greatly appreciated!!!

By the way, even with this headache of negotiating payment with Prometheus, I would do the test again. The results from the test were informative and were used by my doctor to change my Remicade infusion dosage and frequency.

Thanks for any help you can give!!!
01-13-2016, 10:01 AM   #2
Brentobriend
 
Join Date: Apr 2012
I had the same test done, but for humira. Prometheus has a copay assistance program. Call the number on your bill and ask about it. You should only be responsible for $175 or $250, depending on your income bracket. (Even less if you are below federal poverty line iirc). This is completely regardless of what your insurance pays. They were out of network for me, as well, with Cigna. I was becoming immune to the humira, so i switched to remi. I have to get the IFX test done before my next infusion in 8 weeks.
01-13-2016, 04:19 PM   #3
Madhu
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My husband did this test 3 months back for Remicade. Our insurance (Aetna) was also billed $2500 and it was denied since Prometheus is out of Aetna's network. But we were informed of this earlier and Prometheus told us that the maximum they would bill us is $250. GI wanted to do this test with Prometheus, so we said okay. I tried negotiating with Prometheus to bring it further down since we already had to pay for a surgery and loads of pharmacy stuff the past year but they declined. Worth a try though

They haven't billed us yet, now your post has got me thinking if they would stick to $250.
__________________
Hubby dx with Crohn's in Feb 2015, in remission from Feb 2016 to Feb 2017.
2 anal fistulas (setons placed in June 2015 and removed in Feb 2016)

Mild flare in Mar 2017. Remicade schedule adjusted

Current Meds - Remicade 10mg/kg
01-13-2016, 07:05 PM   #4
Jane
 
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Thank you both of you for sharing your experience with Prometheus! I'd love to hear from others. How much, if any, did others have to pay for the test?
01-17-2016, 04:45 PM   #5
syzygy
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I was told by Blue Cross / Blue Shield that the test was still considered investigational and not yet eligible for reimbursement at all. I decided to not go ahead with it and just discontinued Remi based on the side effects I was having.
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Intermittent SBOs starting in 2005
Diagnosed 2013
Started Remicade October 2014
01-17-2016, 05:34 PM   #6
myboy12
 
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We pay $250 every time the test is run. Our Blue Cross Blue Shield denied the claim. Prometheus is willing to set up a payment plan.
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Son diagnosed at age 12, December 2014

Current meds: Remicade every 8 weeks (May 2014)
Past meds: Prednisone, 6MP and 3000 mg Pentasa
03-01-2016, 12:28 PM   #7
mamalana
 
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I had the Prometheus testing done as well, and also was billed the $2500. I called them and asked why my insurance wasn't billed. The lady said, "Oh, we have no record of your insurance!" She took my info and within five minutes was able to tell me that I owed nothing- she applied insurance and patient pay assistance, but beyond that, I only had to pay the $10 co-pay for the lab.
__________________

Dx Crohn's 2014

Current Rx:
Remicade (starting 2/16/16), Imuran, Celebrex, Flovent (for EoE), Singulair

Previous Rx:
Prednisone (pure evil), Budesonide (bad reaction), Prilosec, Bentyl, Protonix, Cimzia (failed after 4 months), Humira (failed after 7 months)
03-14-2016, 02:47 PM   #8
Mehita
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I just got the Prometheus bill in the mail today and am being charged $2250. As you all know the test is $2500 and then it says they've exhausted their appeal efforts with Blue Cross Blue Shield of Minnesota and the remaining balance is my responsibility. The maximum out of pocket was $250, which is how it came out to $2250.

What frustrates me is that my son's GI just ran the test again last month (the first one was a year ago) without my knowledge. When I complained, he said he wasn't aware that insurance typically denies it and apologized profusely, but... I still have to pay the bill.

There was a financial assistance form included with the bill and we'll give that a try, but I highly doubt we'll qualify.

If anyone has any suggestions, I'd love to hear them.
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Mom of DS, age 17, dx Crohn's and Celiac Oct 2008
- Remicade, started Nov 2013, added Solumedrol June 2015
- added Methotrexate/Folate March 2016
- Multivitamins, Probiotics, Vit D
- Small bowel resection, Jan 2013
03-15-2016, 11:39 AM   #9
Madhu
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Wait. The max out of pocket is $250, so why are they charging you for $2250? Something is wrong here. I would check again with Prometheus.

I filled out the financial assistance form too. Spent 6 hrs gathering additional info to try to bring it further down from 250. Didnt work. Worth a try though Let us know how it goes!
03-15-2016, 01:14 PM   #10
hcrum87hc
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My GI wanted me to do the Anser ADA test, which is the same test, just for Humira instead of Remicade. From my research at the time, it looks like the test was roughly $2500, of which my insurance would cover 50% after my out of network deductible of $600. My wife and I didn't qualify for their financial assistance, and I did not feel comfortable spending that much money on the test. Thankfully we decided to forgo the test.

A few months later, my GI sent me to Duke for a consultation to see where to go now that my Humira alone wasn't fully working. It turns out that Duke apparently has a contract with Prometheus Labs, and they were able to do the test at no cost to me. All I paid for was the Duke lab fee, which was covered in network at 80%. It turns out that I was not creating antibodies, and had enough of the dose in my system, so we added Imuran back to my med regimen, and I'm feeling good now.
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Blessed is he who trusts in the Lord, whose confidence is in Him. Jeremiah 17:7.

Officially diagnosed with Crohn's Disease in June, 2014 2 weeks before 27th birthday after ER visit due to partial blockage (stricture).

Current Meds:
Humira-40 mg every other week
Imuran-150 mg/day

Surgeries: Ileocecectomy 7/13/16 removed 60cm of small intestines.

Status: All inflamed and strictured intestines removed. All remaining intestines are currently healthy.
03-17-2016, 01:48 PM   #11
Mehita
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Wait. The max out of pocket is $250, so why are they charging you for $2250? Something is wrong here. I would check again with Prometheus.

I filled out the financial assistance form too. Spent 6 hrs gathering additional info to try to bring it further down from 250. Didnt work. Worth a try though Let us know how it goes!
I called Prometheus and said I just wanted to double check that the bill was right. She said, yes, we were responsible for the $2250. My son also had a second test just a few weeks ago and I asked about that one and she said all future tests, as long as they are done for the exact same disease and reason, are charged at $375. I hung up and while I was panicking on how we were going to come up with the money she called back and said it was a mistake on their part. The numbers should have been reversed ($2500-$2250 = $250) and we only need to pay $250, even though our income exceeds their income qualifications. Quite honestly, I think it was reduced simply because I called and that my son is a repeat customer. Definitely worth the call!

I hate Crohn's.
03-17-2016, 02:06 PM   #12
Madhu
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Oh! Good they brought it down. So true, this is a costly costly disease. I am now looking at Remistart to avoid paying too much next month when hubby goes for his infusion. Ever since his diagnosis, I have a peculiar relationship with his hospital and insurance. I call them atleast once a week
03-18-2016, 02:20 AM   #13
Jennifer
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Some labs charge a fee for it. One charges $30 where I live. The last time I had it done though I wasn't charged a lab fee, it was a different lab. As for the test itself I don't pay a dime out of pocket. I have Medicaid.
__________________
Diagnosis: Crohn's in 1991 at age 9
Surgeries: 1 Small Bowel Resection in 1999; Central IV in 1991-92
Meds for CD: 6MP 50mg
Things I take: Tenormin 25mg (PVCs and Tachycardia), Junel, Tylenol 3, Omeprazole 20mg 2/day, Klonopin 1mg 2/day (anxiety), Restoril 15mg (insomnia), Claritin 20mg
Currently in: REMISSION Thought it was a flare but it's just scar tissue from my resection. Dealing with a stricture. Remission from my resection, 17 years and counting.
03-31-2016, 01:11 PM   #14
Madhu
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Yesterday, my husband's GI said he wants to do the test again in 2 weeks. I called Prometheus and they said we would be asked to pay $250 and not more than that. I hope I can trust their words.
03-31-2016, 03:32 PM   #15
ChicagoMom
 
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My daughter just had this done and our insurance, BCBS, denied it as well, because we used an out-of-network lab. I had already called them and they told me it would eventually be approved if proven to be medically necessary, so now we are in the "medical records review" process. BCBS has approved everything so for, so I'm hoping the trend stays the same. I did go ahead and send Prometheus the appeal paperwork they asked for, just in case it comes to that.
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*R*~mom of *L*~age 14-diagnosed with CD 5/14

Currently taking:
Remicade 10mg/kg
Methotrexate 15mg/week
NG-tube at night

Past meds:
6-mp--discontinued 9/14 because it caused bone marrow suppression
Prednisone--5/14-11/14
04-27-2016, 06:34 PM   #16
MomTo3Boys
 
Join Date: Mar 2016
Location: Boise, Idaho
I'm so angry about this. My doctor ordered a blood test. That's what she told me...you need to do a blood test. I went to my "in network provider" (local hospital) and had my blood drawn. Unbeknownst to me, the hospital sent my blood to Prometheus. No consent, no authorization. I had no idea until that lab started calling me (how did they get my number??) and then I got my insurance EOB and saw my blood had been sent there and of course, my insurance is refusing to pay. I'm livid! I did not ask for my blood to be sent anywhere. Prometheus wants me to apply for their financial assistance program and they want my personal info like tax information, to do so! Ummm NO! That's private. My doc is supposed to write an appeal. I'm sure I'm in for a battle with my doc's office manager. I think it's my right to know where my bodily fluids are going... Grrrr....
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