Insurance and Oncotype

Anonymous

Insurance and Oncotype

macdebbie

I have what seems a simple question, but I can't seem to get an answer. I met with an oncologist yesterday who said he would run Oncotype if I wanted it (I do). I just feel it add another layer of data, and I've read people and docs have been surprised when the score of a seemingly low risk cancer comes back high.

My insurance requires Oncotype to be pre-approved. I've asked two oncologist offices now how that happens, as I know the test is expensive and I don't want to be stuck with the bill. Neither of them could tell me. One shuffled me between 3 different nurses and a financial counselor and still no answer. The 2nd office I asked yesterday and they just said they didn't know. I asked the doctor and he said he didn't know (I didn't figure he would).

I would think this is a pretty routine thing - Oncotype being sent out and insurance having to pre-approve the test so I am baffled. Does Oncotype do the pre-approval? How do I get to the bottom of this? I'm feeling the pain of decentralized medicine....

December11

I think it is the insurance who does the pre-approval. I think the doctors submit something to them for the preapproval

DebAL

December, I think you are right. I had to stop and think because oncotype was sent automatically in my case. I wonder if once ER/PR is determined by biopsy if the ball doesn't get rolling then. Maybe BS office works with insurance then by the time surgery is done its already pre-approved and specimen is sent. I was told after surgery that it was sent. Maybe it would have been discussed prior had there not been pre-approval.

macdebbie

Thanks all.

The BCS told me that after surgery and after she has had a look at things, she notifies the oncologist about the results. He then orders the test (I was told by the BCS's office that they never do this).

The only thing I was told by the oncologist's office is that they will not call my insurance for pre-approval until the order for Oncotype is placed by the oncologist. But.... no one seemed to know WHO does the pre-approval, and I need to talk with them as if they don't do it via phone, and instead use the portal it will be a 7-14 day approval period vs 24-48 hrs.

So frustrating that no one knows who gets the approval! Yikes.

ShetlandPony

The doctor orders it, and the company verifies and bills insurance. They handle appeals. if the cost to you will be more than $500 they call you.They provide financial assistance. Basically they want people to use their test, so just get it ordered, and they will work it out, or call them in advance to talk about it.

https://www.oncotypeiq.com/en-US/resources/billing-financial-coverage

Moderators

Hi macdebbie -- here's some additional helpful information for you from the main Breastcancer.org site: Insurance Information and Financial Assistance for Oncotype DX Tests

We hope this helps!

--The Mods

SpecialK

macdebbie - my insurance functions on 100% referral and pre-auth for literally every service provided by non-military/civilian providers. There is zero cancer care affiliated with my local military treatment facility so that means all of my care has been handled off base by my insurance and all of it required pre-auth. The way my insurance works is the provider, or someone in their office who handles this, requests the pre-approval for whatever the service/test/lab/drug is, and the insurance company then provides an auth number and a letter authorizing. My providers have the capability to both request and receive the auth electronically, and I have received some in as little as 45 minutes. The provider is the only one who can request the auth because they are the ones that know what they are requesting, and the reason for it. It usually means filling out an online form, but can occasionally mean a peer to peer review if the situation is unusual, or require additonal info or backing test results in some instances. The only denials I have experienced were for tests using emerging technology that had not yet been accepted as mainstream practice. In both cases the company providing the test did not bill me, rather appealed to insurance and when denied again they absorbed the testing cost. That is because this was an insurance denial rather than me being an uninsured patient - in those cases they usually employ patient assistance funds for a considerably reduced patient cost. The only other denial was for a colonoscopy that my oncologist was requesting. It had only been four years since my last one, but I had a breast cancer diagnosis with nodal spread, and multiple significant skin cancers that required surgical removal in the meantime. The insurance said I did not meet the risk profile, which made me laugh - how many different kinds of cancer did I need to have to get a screening test that is preventive for advanced cancer, lol! It was ridiculous and my oncologist was confident he could get it approved with a peer to peer, but I just waited for another year and then got it done routinely. Because OncotypeDx is such a commonly requested and approved test I would be shocked if your insurance turned it down. The entire purpose of the test is to determine whether chemotherapy is warranted. If it isn't then the insurance company has saved a ton of money by paying for the test instead of chemo - if the test indicates chemo is warranted the insurance has test results that confirm the need. I am sorry you are having to wrangle insurance issues in addition to coping with the shock of diagnosis - I know it is a lot!