Home Forums Melanoma Diagnosis: Stage IV Insurance Issue and ECOG

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  • #22259
    msue5
    Participant

    I received my first dose of Ipi on 4/22/13 and the hospital ordered the dose through the hospital pharmacy instead of my insurance pharmacy. I was charged $56,000 for that one dose by the hospital since my insurance refused to pay since it was not ordered properly. It took about 10 months of phone calls to resolve this and was finally told it was resolved and Insurance would pay. No more bills for a year and everything seemed ok until last week I received a letter from the hospital stating that the bill was not paid and the Insurance needed more info concerning Eastern Cooperative Oncology Group. What could ECOG have to do with my claim which I was assured was paid already. I called the hospital and was told the insurance never paid. Very confused. I will call Insurance Monday but can’t imagine what is going on. Any ideas? How could ECOG have anything to do with this? This was not a trial and was well after IPI was approved.

    Mary Sue

    #65894
    RJoeyB
    Participant

    Hi Mary Sue, two quick thoughts… (1) I believe some insurance companies use ECOG Performance Status as part of the determination of medical necessity (or appropriateness) of Yervoy, even today outside of a trial setting. And (2), as I’ve learned myself in recent days, there is a big difference, also from an insurance perspective, between inpatient and outpatient chemotherapy — insurance has limited criteria to pay for inpatient, so if the hospital is incorrectly billing that first dose as inpatient, that could be the issue. And perhaps they only pay for inpatient based on ECOG status, so that’s why they are inquiring. Hope that helps.

    Joe

    #65895
    msue5
    Participant

    Thanks Joe. What it seems to boil down to is my insurance is looking for any way not to pay for this dose. There was no issue with the 3 other doses. The $56,000 was for the medicine alone. They paid for the infusion, labs etc associated with that dose. I’d also like to know where the amount of $56,000 came from. This is the price the hospital charged- much higher than what 1 dose should cost.

    Mary Sue

    #65896
    Catherine Poole
    Keymaster

    Yes, things are so complicated for patients that it makes up want to throw up your hands. I admire your tenacity Mary Sue! I thought that maybe Bristol Myers Squibb might want to know about this issue or maybe not. Worth a try and I can reach out if you’d like. Also, there are non-profits who help pay for drugs if you meet their criteria, pan.org is one of them. Joe has the same thinking I had about ECOG status, although I think you are right that the industry is trying to build a smokescreen to the real issue and that is not wanting to pay for this. Let us know what you find out and maybe we can lend a hand.

    #65897
    RJoeyB
    Participant

    Definitely frustrating, and it doesn’t help that I’ve seen both in hospital bills that I receive and EOB’s from the insurance that they roll things up a lot, making it difficult to know what actually goes into a charge and then to match the bill to the EOB — the smokescreen Catherine mentioned.

    It sounds like this is what happened, an educated guess… the hospital probably has two different rolled-up prices for Yervoy, one for it given inpatient and one for it given in outpatient clinic, with the inpatient rolling up the hospital costs, too, making it more expensive. The insurance does not like to pay for inpatient chemotherapy (setting aside that Yervoy isn’t really “chemo” in the traditional sense) because of the high added hospital costs. But one scenario under which they might consider it is if the ECOG Performance Status indicated that the patient isn’t well enough to receive it without being hospitalized. So even if it was initially approved, it was probably approved as outpatient, then if the hospital somehow submitted that first dose as being given inpatient, perhaps the insurance is now asking for ECOG status to understand why it needed to be given inpatient (I’m assuming you know what ECOG status is). So what I think needs to happen is not for you (or the hospital) to get ECOG status and provide it to the insurance, but for the hospital to correctly resubmit it as outpatient chemo. Hope that makes sense.

    Joe

    #65898
    PhillyRed
    Participant

    I really do not think it has anything to do with a patient’s ECOG performance status. ECOG performance status is just a scale developed by the ECOG to determine the “fitness” of a patient for participating in an oncology clinical trial(based on how severely the cancer impacts a cancer patient’s daily living and the patient’s general constitutional strength and resilience). It is more likely that the insurance company is seeking input from the ECOG regarding the appropriateness and recommendations for particular anticancer therapies for individual patients because the ECOG is considered to be an expert advisory panel determining policies and treatment recommendations in the field of oncology.

    #65899
    RJoeyB
    Participant

    I don’t have Aetna, but a quick Google search uncovered this document, for example, where an insurance company is making approval decisions for Yervoy based on ECOG performance status:

    http://www.aetna.com/cpb/medical/data/800_899/0815.html” class=”bbcode_url”>http://www.aetna.com/cpb/medical/data/800_899/0815.html

    Including the following:

    Aetna considers ipilimumab (Yervoy) medically necessary for the treatment of the following malignant melanomas:

    * Disseminated recurrence or metastatic disease in persons with good performance status (Eastern Cooperative Oncology Group [ECOG] performance status 0 to 2)

    * Disseminated recurrence with brain metastases in persons with good performance status (ECOG performance status 0 to 2)

    I’m not saying if it’s right or wrong, only that it is apparently used. The dates on the document are all after the FDA approval of Yervoy in 4/2011 and reference the trial data, but apparently they carried the ECOG PS requirement over to their standard approval criteria.

    Joe

    #65900
    msue5
    Participant

    Thanks for all your replies. I had a thought and wonder if this has anything to do with my having Lupus and Yervoy is contraindicated in autoimmune disease. I was switched from Zelboraf to Ipi when I developed 3 SCC IN 1 week which then had to be excised. It was then decided to switch to IPI but BMS was aware of the Lupus and followed up with my Onc and me weekly. But that doesn’t explain why there were no issues with Insurance paying for the rest of the doses. I will be making calls tomorrow!

    Mary Sue

    #65901
    Catherine Poole
    Keymaster

    Good luck with your phone calls, again, I admire your strength to deal with these folks. I have a theory that much of the industry tries to wear you down so you just give up and pay what they want. When you are dealing with an illness you shouldn’t have to be fighting with your insurance company and/or the hospital over payment!

    #65902
    msue5
    Participant

    Issue resolved I think. The Insurance Co(BCBS) tried to tell me that they don’t pay for Investigational Drugs. I said that Ipi had been approved for over 2 yrs by that time. On hold for 1/2 hr and when she came back on the line she said “you are right”. This will be resolved and paid for. I am relieved but wonder how many people don’t pursue an issue like this and just end up paying. Thanks everyone for your thoughts.

    Mary Sue

    #65903
    msue5
    Participant

    Unbelievable but another insurance issue came up yesterday. I received a bill from the Cancer Center where I get PET Scans. There were 4 scans listed and two were paid out but two were not. It appeared that they were paying for every other scan. I had my checkbook out ready to pay when I decided to call the Insurance Co. I have had mixed results from Yervoy and never NED so scans were important. One phone call and now all scans will be 100% covered. I will never pay another bill until I make a phone call first. Lesson learned! I am grateful for my insurance but are they hoping I will just pay the bills and they are off the hook? It’s stressful enough to have cancer without having financial issues. I feel so sad for the people who have no insurance and no access to proper care.

    Mary Sue

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