There has been some miscommunication between my doctors office and my insurance company. The doctors office called for pre-certification for some infusion therapy and was told that they would allow 4 infusions at a $30.00 copay. Great for me since the infusion therapies are quite expensive (did not know that at the time). Now the insurance is denying this stating that the doctors office misunderstood them and that the only copay they would cover was for an office visit. Bottom line is if I knew that I had to pay almost $900.00 per infusion, I would have gone a different route. I have had 2 infusions and have cancelled the remaining. Where does this leave me. The insurance company has sent it on to their manager for a decision.

Do I have any recourse on either the doctor or Insurance company?

What were you infusing?
Methotrexate (from your previous posts) for arthritis?

The doctor started me on Remicade infusions, but due to the cost he is switching me to Humira self injections. I also am on Methotrexate and Arava in pill form.

I looked around and fund that virtually ALL insurance companies are denying Remicade infusions at home...Were you getting them at the doctor?

In any case, if the doctor and the insurance company miscommunicated, then I think one or the other should eat the cost, not you. Get the documentation if you can...who said what to whom. Have your doctor communicate with the insurance company and verify that he was told that the 4 infusions were pre-approved IF they were.

If you hammer at the insurance company they will probably pay, especially if the doctor has a copy (perhaps an e-mail) of the approval number! If however the doctor acted WITHOUT the pre-approval, he has violated his contract with the IC and he really should foot the bill. Alas, if it goes to court, legal fees are always more than the cost of 4 infusions :(.

Since patients are not privvy to the communications or contracts or payments between insurance companies, they cannot lay on patients the financial blame when they screw up their secret dealings.

I was taking the Remicade infusions at the Dr.'s office until I cancelled them due to the cost. Remicade treatments for me were $4,900.00 per treatment. My doctor's office pre-certified them before I started and told me that I would be responsible for a $30.00 copay for 4 of them and then it would go against my deductible and then into the 80/20 plan. When I realized the cost I cancelled them (after I had 2 treatments) because I cannot afford the 20% of the $4,900.00 per month. Now due to a communication error, I owe $865.00 per treatment and I have had 2 treatments. Ouch! What a shame because they were really helping. I hope the Humira does as well.

The ball is definitely in their court to resolve. I have talked to both, Insurance Co. and Dr.'s office and they are both standing their ground that they were not in error. I have not been billed yet, so it remains to be seen what happens.

Thanks for listening!

First, I would contact your doctors office and get a copy of what was preauthorized by your insurance company.

Second, I would contact your states Insurance Commisioner and file a complaint (should be able to find on your states .gov website)

Third, I would read your insurance plan and follow the instructions for filing an appeal.

let me know if I can be of further assistance.