If there's anyone here who can help my friend with the following issues or knows of someone who can help (Would pay for resolving this). It's a bit long and I hope i explained it correctly
The Story:
He has insurance with a high $6850 deductible. once deductible is hit insurance covers everything no co-pays
He needed to do a medical infusion which hospital would bill in excess of $50,000 retail. hence that procedure would leave him with a $6,750 bill (for the deductible) and the rest would be covered by insurance
Now the drug being infused is the main cost (retail upward $30,000), so the drug manufacturer has a program aimed at high deductible health insurances, where they offer to cover the entire out of pocket cost of the drug minus the first $50. (They are essentially paying the hospital who then pays it back to them for the drug cost, and then the insurance pays the rest)
So he figured after all said and done this would cost $50 (Hospital bills $50K, insurance pays everything minus $6850, drug manufacturer pays $6800 = $50 balance).
The problem:
well of course somehow he ended getting a bill for $1700.
The insurance / hospital did the following: they split the procedure into 2 parts and applied part of the deductible to each part as below
1. The hospital service of performing the infusion - discounted cost - $1700 - deductible applied - $1700
2. the drug itself discounted cost - $18,500 - deductible applied - $5150
Now since the drug manufacturer program only covers the drug portion, they only paid the $5,000 deductible (for part 2). leaving him with a bill for $1700 deductible for the first part.
The question:
If there was a way to get the hospital / insurance to reprocess the claim in a different way, they would not pay a cent more, but the drug manufacturer would then cover the $6700 deductible applied towards the drug, as below
1. the drug itself discounted cost - $18,500 - deductible applied - $6850
2. The hospital service of performing the infusion discounted cost - $1700 - deductible applied - $0
In both cases the insurance ends up paying $13,350
He already tried calling the hospital and the insurance and they do not want to adjust anything. any help here on how to get them to reprocess or anything else that can help would be appreciated.
Thanks!