Insurance question

[Rothko]

I went through the paperwork for Xiaflex at my MD's office, and was called and told I was pre approved (as they don't proceed without).  I was scheduled for my first two shots, which ended last week.  Yesterday, I got an invoice from the hospital (a prominent NYC Cancer Hosp) that I'm being billed 6K for there first shot.  What happened here?  I asked for the original approval fax at the MD office.  It wasn't really an approval, but said that they don't do pre approvals (Emblem Health), and to proceed and bill.  Well, did anyone think to ask me if I could afford it?  No.  Not sure how to proceed at this point.  The first two shots did loosen things up down there, and probably did some good. I would like to continue, but can't pay with this billing scheme.
Does anyone have any suggestions?  My thinking is to get the second round done before I fight this fight, as they may cut me off before if I raise an issue now.  I think I may ask the doctor about it after the fourth shot and ask if their office can intervene, as they were the ones who told me I was approved.  Don't want to get into deep debt with Xiaflex, as I may need to borrow cash later for surgery if this doesn't work well enough to get me back out there.  Anyone with similar experience?

[hope4all]

The first thing you should do is call U.S. Biomedical 855-534-8323, Ext. 6708.  Everything is done through them as the distributor. They will have a file on you. I've talked to them on several occasions and they were helpful.  I've also talked to a very helpful person at Auxilium, named Eric 800-743-2382, ext. 6303. He helped me resolve an issue with my first shipment.  

What probably happened is the hospital sent the bill to you prior to the insurance company paying their portion.  Some hospitals are faster than others in processing records.  

The claim payment may take a little longer because it probably has to be paid by Emblem's specialty pharmacy benefit manager, often times that is Caremark or Express Scripts. Also, millions more people have been added to insurance rolls so claim payments may be taking longer than you are used to due to higher volumes.

Believe me, that drug does not get shipped to the hospital unless there is an authorization from the health plan (the promissory note).

I work for a health insurance company and know all the ins and outs.  NEVER allow a denial of service to go unanswered, NEVER.  ALWAYS appeal, ALWAYS question. Complain to H.H.S., and your state's insurance commissioner, call your local US House and Senate offices, they have constituent services that can help. Believe me, health plans act very quickly when they have state and/or federal regulators calling them.

I too have noticed my plaque softening and getting spongier.  I'm due for my second round towards the end of Feb. In fact, I'll be calling U.S. Biomedical tomorrow to make sure everything is going smoothly with my 2nd order since this is a new benefit year and I have a new pharmacy benefit manager for my health plan.

Good luck!

[Rothko]

thank you Hope4all for your encouragement.  I feel much better today with your support.  Especially the part that I wouldn't have gotten the treatment without prior arrangement.  I will call the folks you have listed.  I very much hope to get the full 8 injections in this series.  

[hope4all]

Hopefully they can help you Rothko, let us know what happens.  Hopefully, Emblem will not make you prove how your curve is progressing after every round. I doubt they would.

Insurance companies are going to handle this sensitive disorder very carefully for a host of reasons. Namely they and their employees don't want to deal intimately with this subject matter or get too involved with individual results or details.

A correction to what I posted earlier on insurance company denials: If a denial is a clear exclusion and there is no doubt in a reasonable person's mind that it's not covered, then it usually doesn't make sense to fight an appeal. In many cases it's a gray area and can be subjective...this is when you fight it.  

[Rothko]

Well,
I got the statement from Emblem that they won't pay out due to the fact that 'prior authorization was not obtained'.  Contacted the doctor's office and spoke to the woman who told me I was approved.  She asserted that I was.  She asked me to fax her the statement.  Haven't heard from anyone since (about a week ago).  I think she made the mistake and is hoping I'll just go away without bringing her name into it.  I also blame Emblem for submitting some 'non statement lingo' back on the original approval request.  Purely a strategic ploy on their part.  Got billed 6K by the hospital for each of the two round one injections, plus an extra $500 for the MD cost for each one.  Don't think I'll be going back for more at this rate.  
Just a word of warning, it is not enough to have this disease.  We are further victimized by the insurance companies and even the hospital billing departments.  Wish I had some good news to share, other than the fact that I'm getting used to living a celibate lifestyle.

[hope4all]

I'm sorry Rothko, but U.S. Biomedical and or Auxilium are as much to blame for shipping the drugs prior to receiving the authorization.  I would get on their asses as well. Call them and don't stop calling, every single day, until this gets resolved. I"m totally serious. Keep talking and talking and talking, annoy the f out of them so they relent. That is the name of the game. If you don't fight for this, nobody will do it for you. You are just a patient number to the billing offices involved. This applies to your insurance company too if that's where the problem lies.

Unfortunately with the US healthcare system the onus always comes back to the little guy, the one who can least afford it, the patient. We sign our rights away every time we see a new provider. If we don't sign, we're unable to see the doctor, so of course we sign the paper, and hope that it will be paid for; that all the i's were dotted and t's were crossed in the background and in 4-6 weeks we'll get an explanation saying we owe whatever portion is our responsibility.

The insurance company can still backdate an authorization, they do it all the time. Ugh, i feel your pain, I really do. I'm part of this inefficient and infuriating system and it sickens me that we have to go through this crap.  DO NOT STOP FIGHTING until this gets paid for by someone other than you.  PM me if you need more advice on how to deal with your insurance company.

[Rothko]

Thanks Hope,
I have decided to discontinue the Xiaflex at this time.  Not sure the first two shots helped anyways.  I've decided to put my money on implants, as the Peyronies has slowly killed my erectile functioning over the past four years.  I thought the Xiaflex may have improved it, but won't really ever know for sure now.

Going to see Dr. Kramer in Baltimore for surgery (self pay, of course).  Not giving up.  At least I have resources.

I have two friends my age that also developed Peyronies at about the same time (both HIV+), one with a worse case and one in Canada that says he can live with it.  My friend with the worse case has no resources to address it.  He's heartbroken.  He belongs to an HIV+ support group and found out that half of the 16 guys in the group also developed Peyronies.  I think the Peyronies and HIV community haven't made the connection yet, but empirical evidence seems to show a connection.  This is what we get for surviving the epidemic.  Still keeping hope.

[hope4all]

Rothko, I hadn't heard of that connection between HIV and Peyronies, but I wouldn't be surprised. Forgive me for my ignorance, as I'm negative, but I would imagine the immune system plays a role in both conditions. I remember my injury happening around a time when I was low on Vitamin D and E, stressed out from work, and drinking more heavily than normal.  

I'm so sorry your experience with Xiaflex has been a dud. I remember feeling hopeful with every new treatment I tried after being diagnosed only to be eventually disappointed. I lowered my expectations with Xiaflex...we shall see.  

I wish the best of luck with your implant journey and hope you will continue to post on your experiences with that process here on this forum.  I've read many long time ED sufferers rave about their new bionic members, i  hope you will too!

Best,
Hope4all

[blackdiamond]

I've asked his question before...Does anyone know if Xiaflex is covered by Medicare....Any response would be much appreciated ......Thanks

[hope4all]

Blackdiamond, I found this on a NYC doctor's website:
"...most insurances provide coverage for Xiaflex, including Medicare, UnitedHealthCare, Aetna, Blue Cross plans and many others.  We work through the Xiaflex Experience program to get your insurance to cover the costs of treatment.  Insurance coverage may also be available for some of our international patients."

If you google new york urology specialists it should come up. If you have a Medicare Advantage Plan I'm not certain how that would work, but if you call a Urologist who treats a lot of Xiaflex patients they will know right off the bat. If you call a dr.'s office, even if they are on the list of doctors provided by Auxilium, and they say "what is Xiaflex? or Peyronies etc." call another doctor's office.  Offices that have a high volume of Xiaflex patients know the process backwards and forwards and the doctor will have way more experience.  

[blackdiamond]

Thanks so much Hope4all......