PSMA scan costs part 3

[TJGuy]

So in two prior posts, I wrote about what I was told a PSMA scan would cost. Then I wrote about what the hospital charged for the procedure.Now I have the EOB from insurance.

So this is in the USA, for those international patients.

So hospital billed

$29,610 for the scan plus $7,305.70 for the facility charge. I also had office visits and RO and MO charged. So those were $782, $437, $452.05, $422

Now the allowable charges were

$13,353.11, $3,294.87, $311.45, $275.54, $203.87, $198.43

So the cost for me to get a PSMA pet scan and

Discussion before, and after came to.

Charged $39,108.75

Allowed $17,637.27

I paid $7,500 deductible of that

So BCBS denied me getting a scan at MAYO

I then went to another hospital to get it approved, these are those costs. Then had the scan sent to MAYO to be read. So there was additional cost these which I'm not showing.

Result scan machine and software used left it unclear if one or two lymph nodes need radiation. Need to certain, before radiation due to area it's at.

So will redo it again at MAYO once 3 months pass. Idea is their machine is newer and better and software is better to get a definitive answer.

So here is another example of BCBS interfering with doctor patient care. Resulting in lost time, this should have been all resolved in June 2023 at MAYO. Increased cost, and a great deal of stress, frustration, made and then cancelled travel, hotel, car reservations.

Will go back through BCBS approval process, won't that be fun! And probably have long drawn out appeal process.

Isn't health insurance in the USA great!!!! Go BCBS you're the best. Actually BCBS is the best, what a sad commentary on heath insurance in the USA.

Remember I could have received the PSMA scan with a prescription from my US doctor in BC Canada for $2500 cash. And had it performed within days of my request, at my convenience.

[Hidden]

And people criticize Medicare Advantage programs.

My last PSMA/PET was $50 copay. PERIOD. Radiologist reading $0 MO appt $0

It was too early after RT, so next on in October, not auth needed.

[mrscruffy in reply to Hidden]

Yes I love my Advantage plan through United Health. I don't even look at the bills because I know they will be reasonable. Now the donut hole is another thing but they have no control over that

[TJGuy in reply to Hidden]

Actually getting on Medicare advantage is the last thing you want to do when your on Medicare. Especially if you have cancer or a sickness.

Do not do this, your giving your guaranteed medicare healthcare with ability to get service anywhere in the US, right to specialists, right to hospitals, without insurance approval etc etc etc.

Google warnings about Medicare advantage. For example you won't be able to go to major cancer hospitals like Mayo they don't accept it.

I thank you for your response but no one else in the US should do this. Say on regular Medicare.

[SilverSeppi in reply to TJGuy]

ABSOLUTELY 1000% CORRECT.

[WoodChuckHill in reply to SilverSeppi]

2000% Correct!!

[Explorer08 in reply to TJGuy]

It depends on your plan specifics. I have United Healthcare Medicare Advantage and get all my care through University of Colorado Health/CU Medicine. The only time I have a copay is for an in-patient hospital stay. Coincidentally, I just had a PSMA PET scan yesterday. It was pre approved and I had no copay. My particular version of Advantage has been fabulous…at least so far. Again, it depends on what version one has.

[Mormon1 in reply to TJGuy]

G or N Plan

[j-o-h-n]

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Good Luck, Good Health and Good Humor.

j-o-h-n Thursday 08/31/2023 4:56 PM DST

[SilverSeppi]

Not sure what 'BCBS' is but it sounds like an 'advantage' plan (so incorrectly named). This is why original Medicare is the way to go, 'advantage' plans are a scam. Sorry you had to put out all that $. I have had 3T MRI, biopsy, PSMA pet scan, blood work and many other tests and doctor visits and LITERALLY not paid A NICKEL. Maybe too late but see if you can get off the 'advantage' plan (unfortunately not likely due to medical underwriting). But bottom line is you cannot put a price on your life. Hang in there.

[Hidden in reply to SilverSeppi]

OK, we know how you feel about Medicare advantage plans, so you can step down now.

[TJGuy in reply to SilverSeppi]

I'm not old enough for Medicare yet, so buying health insurance in the private market, needing that PPO plan.So Dr at MAYO does not do peer to peer with the insurance company. Reportedly he's a doctor to 50 % of all advance PC patients in the US. To deal with peer to peer would take take up too much of his and staff time.

[Hidden in reply to TJGuy]

Typical with company like BCBS. Deny all claims, knowing Dr too busy to P2P.

[TJGuy in reply to SilverSeppi]

Blue Cross Blue Shield

[maley2711]

what was the reason given to BCBS for having a PSMA PET?

[petercraig2]

Sounds too much.

As there was no PSMA scan in Canada I flew to Berlin had a GA-68 PSMA PET/CT scan with consultation with Director of Oncology at Charite Hospital all in for about C$5,000

[TJGuy in reply to petercraig2]

When was that? The private Canadian facility I found near Vancouver BC charges $2500 in US dollars for American patients converted from Canadian money which was over $3000 Canadian. See my part 2 post

[petercraig2 in reply to TJGuy]

I had Ga-68 PSMA PET/CT scan in 2017 for 3,500 Euro or about U$3, 800 plus airfare and hotel.

There was no alternative in North America at the time so I thought it was pretty reasonable.

Scans provided the hard information on actual locations of cancer lesions to determine best therapy options.

[Cancer2x]

Damn! I am scheduled for my first PSMA Pylarify scan in two weeks. On Medicare, have a BCBS Supplemental plan to go with it. I hope it is covered, else I would have to defer the scan. I need to call Dana Farber to verify my cost now.

I could go to the VA I guess, but

1) I am not sure they even do it, and

2) I trust the VA as far as I can toss a grand piano. (100% P&T Disabled Vietnam veteran.)

[traxcavator in reply to Cancer2x]

Hello 2X,

I'm also a Viet Nam vet on 100% disability.

My thinking is that my disability money is a government grant to do what's best for me.

I use VA as a resource, and give them as much credibility as the mainstream oncologists (near zero). I can jump through a few easy hoops and get VA to pay for whatever medical care I choose in the community. I pay a few 'nuisance bills' in the low hundreds of dollars, which is not a problem with disability money coming in. Some of the people in the VA system are also veterans, and are a bit easier to deal with than non-veterans.

It also seems that a lot of the VA is similar to mainstream medicine: They look at some numbers, and try to push square pegs into round holes. Getting anyone in medicine to look at YOU rather than some numbers isn't easy. (My daughter is in the business, and I often tweak her about making assumptions based on demographics.)

Good luck,

John

[Cancer2x in reply to traxcavator]

Welcome home buddy! Yeah, the VA has a great insurance policy- if you lose a leg, they help you look for it.

[ELOfan]

Wow! Thats probably gonna happen to me too.

[Sunnysailor]

our oncologist at Mayo says that he thinks alternating between conventional CT and PMSA is best because PET doesn’t show enough fine details. Pmsa is great for lighting up and exposing the Mets. The conventional CT allows them to see the tissue surrounding the tumors.

My husband is a recently retired engineer for medical imaging and agrees with this. He worked with CT, PET, and MRI.

The PET scans at Mayo are pretty recent models. They had 5 and also have their own cyclotron for making the radioisotopes. Most places have 1 and have no cyclotron, they get it drove in.

The Onc also said insurance is super picky at what they cover per year. That also makes the rationale for conventional CT and then going PmSA if needed once you have a basline and low pSA with active surveillance. It might not be a good option if your PSA is rising . Just a thoughts

I do agree that it’s ridiculous that you have to jump thru hoops to get your care.