No, I am not giving you $75. Suck it.

The BBQ Pit
1

I normally get IV infusions every 6 weeks. The cost for this is a specialist visit co-pay of $50. The medication for the infusion costs a lot. The doc estimates between 25 - 30K per year for this medicine.

So back in April, I needed to move up my infusion due to an out of town trip. The doc couldn’t source the meds the normal way, so called upon CIGNA’s Tel-Drug program. They happily sent along the drug, and I got my infusion, and a bill for $50.

A bit later, I got another bill, from Tel-Drug. It seems I have a $75 co-pay for non-formulary brand name drugs dispensed in doses over 30 days. So, I contacted them and explained the situation, how I normally receive the drug, etc etc. Nope, they don’t want to hear it, I owe $75.

I escalated it through HR as well. Nope, the claim was processed correctly, you owe $75.

Now, I understand having cost differentials in place when services seem similar but offer widely different cost structures, such as a different co-pay for ER visits vs PCP visits. I get similar service (“Take 2 aspirin and call me in the morning”) but the cost structures are widely varying because of the expense of operating an ER vs a PCP office. In this case, however, the insurance company is being asked to pay for medicine. It is HIGHLY likely that CIGNA has a better negotiated price for Remicade than my doctor does, so it’s probably even cheaper for them to dispense it through their pharmacy. I realize that the contract says you can screw me this way, and that you feel obligated to your shareholders to screw me this way, but I look at it this way: $75 is a tiny percentage of the medicine’s overall cost to you. Maybe 1 or 2% However, to me, this represents an increase of 150% to my typical costs, for ZERO net benefit to me.

On my billing notice, it says that I should not delay payment because that may affect future services from CIGNA Tel-Drug pharmacy. Rest assured Tel-Drug pharmacy, I will not ever be utilizing your services again, and have no intention of paying for your stupid convoluted rules this time, either.

2

No, I am not giving you $75. Suck it.

Well, it’ll only be $50 then.

3

Not for nothing but wouldn’t the net benefit to you be that you got to move your infusion up due to an out of town trip? The other option would be to move your trip. Not sure the ROI on either of those options, but it seems there was, at the very least, an indirect net benefit to you.

4

I’d think you’d be willing to cut 'em a little slack since you’re getting $25-30K worth of medicine a year for about $433.33.

5

Yes I suppose I should be thankful and just pay it, but insurance oddities are just such a pain in the ass. It really makes no sense.

6

But these little money-making tricks of insurers are exactly why we cannot control costs. There is no set, uniform “menu” of what anything in the medical field costs because everything is controlled by various subjugate clauses of different contracts and the exact same medication given to the exact same patient for the exact same ailment by the exact same doctor in the exact same room costs fifteen different things based on which day of the week it is, what color tie the doctor is wearing and which way the wind is blowing when a data entry clerk in Malaysia keys in a four digit code back in 2004. (Yes that anachronism was intentional.)

If the cost of the medication to crazyjoe under his plan is $50, then sourcing issues entirely out of his control should not alter his cost. This is a joke. And he’s right to fight it tooth and nail.

7

I agree with both of you. I’m just thinking that $75 (although that can be a budget-breaker for some budgets) is small compared to the ‘true’ cost of the medicine in this particular case.

My insurance gripe is that one medication I’m on (super duper fish oil capsules) costs $168 a month, and the insurance I’m on doesn’t give any discount on that (although it does give a discount on the other two meds I’m on). Some times I have to take fewer capsules than I’m supposed to, to stretch it out.

8

I’ll agree with you there. I had a rant about it not to long ago. Some is billed directly to me, some to my employer. Some bills apparently circle the earth for a few months and then land on me. Nothing is consistent or predictable.

Paying medical bills is sort of like having a second job. I stayed on top of the bills from my shoulder surgery, and made some calls and got the anesthesiologist to send back $1400 that I overpaid. They billed me and the insurance company. We both paid.

My Wife and I are in good health. But things do happen. The amount of billing paper work from my Wifes hand surgery and my shoulder surgery is ridiculous.

“This is not a bill but you are responsible for this”

Huh? What exactly does that mean? It’s sort of passive aggressive.

So you want me to badger my insurance company to pay you? Isn’t that YOUR job?

“Hey Fred, how ya doin. Jim owes me money. Go over there are tell him to pay me or I’m gonna punch you in the nose”

9

No, not really. You agreed to pay whatever wasn’t paid by the insurance. If the insurance company doesn’t pay up in a timely manner, that whole bill is all yours. The medical office will get their money one way or another from somebody; they don’t care who pays it, so long as it gets paid.

Basically, it’s more like this.

You want to buy something from Tom. For various logistical reasons, you work out a plan where you’ll take the goods with you today, and your friend Jim will look over the invoice, come by later and pay the part of the bill he thinks is reasonable, then you’ll pay off the balance. So you take the goods with you, and agree that you owe Tom whatever portion of the bill Jim doesn’t pay.

A few weeks later, Jim still hasn’t made with the money, because he’s been busy practicing for the all-city Chia pet "hair"styling contest. (What? It makes as much sense as any of the reasons I’ve ever gotten from an insurance company for why they haven’t gotten around to paying a claim.) Tom is getting antsy about not getting any of his money that you agreed he would be paid. If he calls Jim, odds are quite decent he’ll learn that Jim doesn’t think any of the invoice is reasonable and isn’t paying anything, so Tom should call you to collect his money. Or he could cut out the middle man and just call you in the first place.

“Hey, Fred, it’s Tom. You know that stuff you bought on account a while back, that you were going to pay whatever Jim didn’t pay? Jim’s not paid anything, and it’s been a long time, so you need to pay all of it. If I haven’t gotten my money by the end of the week, I’m coming over to sock you in the nose.”

At this point, not wanting a sock in the nose, you either pay the whole thing yourself, or you call Jim wanting to know what the everloving fuck he’s doing twiddling around like that and pressure him into paying part of the bill. Either way, Tom’s happy, because now he’s got his money, and he didn’t have to go to the hassle of going anywhere and socking anybody in the nose.

10

Lovely. And I know that nothing is free. But that is quite a statement. Perhaps you should badger the insurance company? Or do you just like to aggravate people in hospital beds?

Why then, does the provider bill me AND the insurance company if it isn’t to double dip?

We have this thing called networks and computers. The billing doctor/provider and insurance companies should perhaps look into it. Why do my providers bill me AND my insurance?

Perhaps they should look into some linguist or a basic English class.

“This is not a bill but you are responsible for it”.

Huh?

That statement is nothing more than an open ended threat.

My interpretation is this –

“We may get money from your insurance, we may not. We aren’t really sure because our systems and communication are so screwed up. And we don’t care. If we fail to get money from your insurer because our systems are messed up, we are going to come after you, and we are going to fuck you up because we can’t do our jobs and we are just as confused as you are.”

11

No, no, you have to understand it’s the insurance companies that are so screwed up. There’s this thing called “delay in payment”. Officially it’s illegal, but it doesn’t stop insurance companies from doing it as often as possible. If a doctor’s office files a claim, if there is ANYTHING that could even remotely be considered incorrect or incomplete (something not being fully in a box on a form, for example), the insurance company will reject the claim and make the doctor’s office file it again…and again…and maybe again until the insurance company is finally badgered into paying it.

Some doctor’s offices don’t want to deal with this hassle (particularly if they happen to deal with out of state patients) and bill the patient for the balance in full then wait for the insurance to reimburse the patient. Sometimes the doctor’s office gets both payments, and they should refund the patient. But doctor’s offices aren’t doing it with the intent to double dip (at least, most aren’t), they just want to get paid SOMETHING.

For all everyone says doctors make a lot of money - some do, but most are struggling to stay in business with increased costs and decreased reimbursements.

</hijack>

12

All of this and yet people think that a single payer system would somehow be worse. I don’t get it.

13

Yeah, I feel you man. I mean how else in the world would a guy get 25-30K per year worth of treatment for $50 every 6 weekks?

14

I’d like to share my experience. I live in Canada (Alberta) and I’m taking a nearly identical prescription as the OP, and the cost to me is almost exactly the same. The full cost of my prescription is about $800 per dose, once every two weeks (so about $20,000 per year). My portion is only a $25 co-pay every two weeks, plus a monthly insurance premium of $40. (It’s a Blue Cross supplemental drug plan, which is subsidized by the government).

The OP is taking Remicade and I am taking Humira. Remicade and Humira are very similar drugs that are used to treat many of the same conditions (I take it for Crohn’s disease). The major difference from the patient’s perspective is that Remicade is administered by IV and Humira is done by injection (I can do it myself at home). From what I understand, Humira is a newer drug and it was only more recently approved to treat my condition.

Once my doctor said I needed the drug and she submitted the routine paperwork, my drug coverage was approved for one year worth of refills. I call the pharmacy and they get the refill in the next day (it can’t be kept on hand since not many people take it and it needs to stay refrigerated). I don’t have any idea how the pharmacy orders it in, and I don’t have to concern myself with paperwork or where they get it from. If something goes wrong with a refill (say it’s not refrigerated properly or the syringe breaks) I can get an immediate refill with no questions asked, even thought it’s an “early” refill. I usually get one month at a time, but if I needed to get more than that ahead of time due to a trip, I could get up to three months at once and then keep it in the fridge at home until I need to take it.

15

This is a false statement.

Firstly, the OP is part of a group medical plan. His employer presumably pays all or part of his monthly premium, which could be anywhere from $300-$1,000 a month or more depending on his age and health. This is part of the compensation that the OP is getting for doing his job.

Secondly, the idea of group medical coverage is that the members are pooling their risk, (and their healthcare dollars). For every member getting $30k in benefits, there are hundreds who are getting little or no benefit every year, despite paying their premiums.

Thirdly, it’s really unlikely that the healthcare company is actually paying $30k for the OP’s medication. They all have negotiated prices that are much cheaper than what the “retail” price would be for someone with no insurance.

16

It’s still $25 to $30 k’s worth of medicine, with the OP spending $50 of his own money.

I understand what you mean about the employer compensating the employee with paying the medical insurance premium. Are you saying that since this cost goes toward paying for the treatment that the OP is paying for it somewhat?

Other people’s premiums pay for it too, but that doesn’t affect the OP.

The price paid by the insurance company for the medicine doesn’t take away from its “worth”. Well, maybe a little.

17

If I were to switch to Humira, I would pay about $25 per month instead of $50 every 6 weeks. However, my doctor says there is not a lot of practical difference between the two, and for now I am content to stick with what is working, at least marginally. Beyond that, I have been having a good deal of problems lately so seeing the doc on a fairly regular basis is warranted, so I would have to pay $50 for a visit and $25 for the meds, which would end up costing me more.

18

It doesn’t change his worth, but the OP is spending far more than his $50 on his healthcare, it’s just not visible as a direct cost because it is paid before taxes by his employer.

Let me give an example: My wife’s health insurance costs us $300/mo, out of pocket, after taxes. So she spends $3600 on healthcare a year, whether she goes to the doctor or not. So if she goes once and has a $20 co-pay, is her cost $3620, or $20? The answer is neither, it’s insurance, not a physical good that she’s paying for. Depending on luck, her actual healthcare needs could be $0 or $200,000. The insurance is a way to hedge that bet, and spread the risk over a large group of people.

The point is that in this case the OP may be getting more than be pays in, but that is the bargain we make collectively by having health insurance. He pays his premiums whether he is sick or not. Myself, I’ve been paying in for years and have hardly needed to use it. Them’s the breaks.

19

Yeah, I see what you mean, but I interpret the portion “spread out” over the other insureds’ premiums differently. I’m splitting hairs I think. Thanks for the explanation.

20

Call them back and tell them that if they don’t back off, you are going to file a claim with your state’s Department of Insurance. A friend of mine who works as a Paralegal told me this trick. So far, at least for me, it’s INSTANTLY done the trick.

Apparently it’s a real PIA for the insurance companies to receive a complaint. Tons of paperwork involved, etc. Give it a whirl and if the threat doesn’t work, then actually file a complaint. Because it’s BS that they’d make you pay more because you have the audacity to leave town.