Topic: ONCOTYPE DX OUT OF NETWORK??

Hi worriedhubby,
First I want to say how lucky your wife is to have such a supportive husband. I have BCBS and had the oncotype in Dec of '06. Same idea--it was out of network and they originally said they would only cover a percentage. The Genomic company told me to call them and they would work with me on the balance. They were wonderful and ( so far) I have not been billed for the balance. I would call them--they will assign you a counselor and they are quite helpful and told me they have even paid for someone that makes 2 K a yr!

I have blue cross and was only told they have no policy on it.  I am worried about the amount they will pay, but guess I won't know for a while.  I was told by Genomic that I only qualify for a reduction of like $200 - I guess that's better than nothing, though. 

I guess they account for household income reduced by rent/mortgage, car payments and college tuition.  I have no one in college this year, but will next year - maybe it'll drag out that long, and then I can deduct that too. 

Thanks for the responses.  My understanding is that BCBS does in fact approve the test.  But as I said under another thread, the insurance company is never the final arbiter about what will or won't be covered under the contract.  Most States have a process to dispute an insurance company's decision once your appellate remedies within the insurance company itself have been exhaused.  And when all else fails, you can always take the insurer to court.  If it is a group policy provided by an employer, that is often an ERISA policy and you can only take it to Federal Court where a judge decides if the company has been arbitrary or capricious.  If it is an individual policy or a policy provided by your government employer, the insurer is regulated by your State's laws and you have a legal remedy, probably with a jury, in your States Courts.  In Florida, if you sue your insruance company and prevail, your attorney will be paid by the Insurance Company, so often attorneys take these cases on a contingency or for a reduced rate.  Same thing with Erisa policies, although there attorney fees are at the discretion of the Federal Judge.

When I inquired with Genomic about Oncotype testing, they said that they accept my insurance.  But the rep I spoke with said to  speak to my insurance anyway just to be sure. 

I did and the answer I always get from their CS is if the doctor requires it for your diagnosis then it will be paid for by the insurance.  Well, it was my med onc who told me to get that test done.  So, in short - I got my results.

During that initial conversation and a few more follow-up calls, I was told that if insurance denies, they will appeal - 3x and if insurance still deny, Genomic will write it off.  This is what I remember as I do not want to be stuck with a bill that big on top of what I already had at that time, and more coming..... 

My insurance, I believe, paid 80% or 90% as, Genomic is indeed out of my network.  I did not even know that back then.....

I have not heard back from Genomic about the remaining portion of the bill.  

Although it is true that Genomic Health is the only company providing the "Oncotype DX" test (it is proprietary, after all), it is not true that "Genomic is out of all networks..." 

Genomic Health is in-network for my insurance coverage.  The first EOB statement I received from my insurance company regarding my Oncotype testing said I owed Genomic Health around $350 (approx.).  That wasn't consistent with what I knew my coverage to be, so I called my insurance company.  The customer service representative assured me that the statement was in error, and the claim from Genomic Health would be re-filed.  She said my obligation was "zero", because Genomic Health was "in-network" and the charges should have been paid in full.  Genomic Health told me a couple of weeks later that they had received payment for the remainder of the charges and the balance-due was "zero".

YMMV, as usual.  I'm sorry to hear about the trouble some of you are having.

otter 

Thanks.  When my wife was diagnosed I purchased the Quicken Medical Expense Manager.  Its inexpensive, easy to use and helps keep track of charges, adjustments, etc. so we are not overbilled by anybody. 

I do not intend to allow Blue Cross to get away with the out of network charge,  I'll take it beyond an inhouse dispute  if necessary.  I must admit that trying to talk to Blue Cross representatives about this was an exercise in frustration.

I am with ya.  We got our EOB with the amount they would pay.  I have Sagamore plus.  When I called they said it was covered 60/40 because of out of network.  I am currently appealing on the grounds that of course it is they are the only ones in our country who do the testing and that test saved my insurance thousands of dollars in chemo bills because without it they would have done chemo.  Good luck!  Maybe they just want to see how hard we will work to get it paid.

If a politician can help you that is great, but my preference is to sue.  If BCBS ignores its own appellate procedures, that coudl be an automatic win.  Really the people who make these coverage decisions simply don't think some of the time.

Just got my EOB from BC - they paid 100% after the provider discount - I'm, of course, thrilled!

Blue cross shield of florida covers the test.  I would think they would througout the country:

http://74.125.45.104/search?q=cache:nF0vXbeAdoUJ:mcgs.bcbsfl.com/index.cfm%3Ffuseaction%3Dmain.main%26stage%3Dpub%26format%3Dcfm%26doc%3DAssays%2520of%2520Genetic%2520Expression%2520in%2520Tumor%2520Tissue+blue+cross+shield+florida+oncotype+dx+network&hl=en&ct=clnk&cd=3&gl=us

I just got off the phone with Genomic health and they said 80% of the time BC/BS pays, but when they decide to file it out-of-network instead, the company files appeals, if that fails and the bill would be $1,000 for me, then they work with the patient to reduce the amount owed.  In my case, based on my 2006 federal return, I would owe them nothing!!!  Holy Cow!!  i was so grateful, I almost cried!

I can still hope that the insurance will cover it, though.  I pay them enough for my coverage!

Susan

I have Blue Shield of California HMO and the Oncotype test is covered 100% as in network. Perhaps your oncologist would write a letter of appeal outlining the neccesity and potential cost savings. It seems somebody on this board had the same trouble and when their doctor sent a letter of appeal, Blue Cross relented and covered it.

I am curious if you purchased an individual policy directly from Blue Cross as opposed to group policies issued through employers. Our policy is through CalPers, and I wonder if the larger insured pool affects the coverage.

Stupid stupid insurance companies. Don't they realize that the Oncotype test will save them millions of dollars in the big picture? Or do they WANT to spend money on chemo therapy for people who may not need it?

Mandy - Genomic also called me and said that my carrier had no policy, so they weren't sure if or how much would be covered.  Sounds like they gave you the same information they gave me.  I told them to go ahead with the test and I would deal with it later.  It really didn't take too long at all for me to receive the EOB with 100% coverage, so I didn't have to do anything additional at all.  I am in PA as well, and am covered by Capital Blue Cross.  My results of the Oncotype came back low - so I was able to avoid the chemo - saving them money in the long run.

I had the oncotype DX and Blue Cross, they paid for 60%, I called Genomic Health and they took care of the rest of it.  They were wonderful!  God Bless and Good Luck. Blessed

I highly recommend filing a lawsuit in your local small claims court against any insurance company that refuses to cover this test.  You don't need a lawyer and if your insurer wants to defend the claim it will have to hire a lawyer and probably spend more money than the cost of the test.   The FDA approves it and Blue Cross itself has stuff on the web about the reliability of this test.  It is no longer experimental and there should be no basis for any insurance company not covering it.  Don't let those bastards get away with it.