Insurance cost for IMRT

[Payal108]

Need help, Can you please share approved cost of IMRT by different insurance companies for 28-33 fractions.

I was misled to believe that cash is cheaper compared to Insurance, now it turns out to be other way around. I was told Insurance and cash rates are 220,000/- but by paying in cash I can get 50% discount on PET scan so saving ~11,000/- . Now it turnout to be (as told by this hospital) that Insurance rates are 190,000/- not 220,000/- , 30,000 less compared to cash.

I down loaded CGHS ( Central Govt Health Service) rates, approved IMRT package rate are ~130,000/- only.

I am looking to confirm if Insurance rates are 190,000/- or still lower? There may be variation from one insurer to another, I believe this difference should not be much.

Thanks

[roxboxfox RadiationOncologist]

Govt sector have got no clue and they u have 10 fractions, 30 fractions or 1000 fractions of IMRT:. If it's the word IMRT written they would have the rates as quoted by you.

CGHS have their guidelines and threshold

Army an Navy may have their own

Rajiv Gandhi scheme for the poor ( I think specific for Maharashtra) have their limits

ESIS, air India have their own limits.

In all the above( a top class officer, executive has higher insurance Vs ordinary worker).

In private setup, sky is the limit.

You go to five star hotel...the cost for a coffee may be 500, If u go to Costa coffee it may be 400, if u go to 3 star hotel it may be 200, if u go to simple hotel it may be 50....if u have it on road it may be 10-20 bucks.

In private sector the hospital decides the rate. It's a business for corporates who have invested cores on the machine, who are spending lakhs on its maintenance, insurance, staff, electricity bills are 1-1.5 lakhs etc to run a Linear Accelerator.

The insurance companies may have their Cap...based on what they think is reasonable. If the hospital and insurance have a tie up...they have mutual understanding and rates can fluctuate 0-20%.

Any hospital may have the right to fluctuate their rates.... Up to 10-15% or so.

There are lots of permutations and combinations possible.

[Payal108 in reply to roxboxfox]

Definitely in free enterprise there is no limit on pricing.

But coming to my question:

1) General displeasure around misleading (specially when concerned staff and us had build a trust through a common friend from the Medical field itself and had 5 month of contact before the event), this is one thing least expected. It was general outburst, not looking some specific help with it.

2) About rate, I was looking input from all the people in the forum. Let me be more specific, if someone has 3 Lakh insurance or 3000/- per day room rent limit. in such scenario what is the IMRT package cost hospital offer or insurer approves.

I believe in Bangalore market what Insurer settle with Kiran Mazumdar Shaw / HCG / Manipal Hospital/ Apollo is not going to be vastly different. Even if it different, that' ok it will help us as patient understanding it.

It is more a survey, I hope it is not beyond the mandate of the forum.

[sumeet_shah Administrator in reply to Payal108]

I can understand your anguish. But no one can actually give an answer. Also, cost of radiation has no bearing on your insurance. It is your choice purely and package you select. Of two patients with both 3 lakhs mediclaim with room rent limit of 3000 per day, one may opt for IGRT, costing more than 2 lakhs while other may go for simple 3DCRT which may be less than 80k. There is absolutely and absolutely no bearing with insurance limit. The insurance companies may have limits; I am not aware of what those are. You may write a common email to all insurance companies and seek answer; they might tell you. And if you were to ask, how do insurance companies decide which to sanction and which to not, even we do not know. It's because the person who decides fate of insurance being passed is not some qualified person. And there are lots and lots of factors which come into play. For one given patients, if she takes radiation in one hospital, the insurance company may not give even half the amount, while if she were to take it in some other hospital, she might even get full amount. So it also depends on how the insurance company views that hospital and other such factors

[Payal108 in reply to sumeet_shah]

Thanks Dr Rohit,

Had this MSW (the person who gave me estimation, that' what it is called in this hospital) not given me any estimation or given correct one I would have gone with insurance and save some money as I had purposely not utilized my insurance in chemo cycles fully.

Anguish is more because the Consultant (Dr) with whom this MSW is attached to in the hospital, I have been consulting him as guide form the beginning of the treatment/surgery on the recommendation of common link (another Radiation Oncologist) and the in-difference shown later on, with out any admission of mistake.

I see insurance discussion is a lengthy topic, will leave that for some other time.

Thanks

[sumeet_shah Administrator in reply to roxboxfox]

Agree fully with Dr. Rohit.

[roxboxfox RadiationOncologist]

Its not at all transparent. Even if a person has 10 lakhs insurance, I would still advocate 3DCRT as the Standard of care for Breast Radiotherapy at least ... for other cancers like Head Neck Cancers, Prostate, Cervix... IMRT has been proven superior to 3DCRT which makes IMRT the standard treatment.

IMRT in breast is used in very specific conditions: where clinician feels its usefullness for large breasts, altered chest wall structures or when heart doses anticipated with 3dCRT are anticipated to be unacceptable.

The Insurance company does not decide the Cost of IMRT, its the hospital / institute which decides... it may or may not have negotiation with hospital

eg IMRT or 3DCRT on menu card might be 130000.. A person has 3 lakh insurance, and claims for 130000, however the insurance company have tie up with hospital, and u r 3 lakh limit will be utilised and reduced to 170000 on paper. (However actually the insurance company only pays 1,10,000 to the hospital because of prior contract and discount via TPA).

Everybody involved wants to make money somewhere or the other... this is all considered legal by the way.

Buying 100 bucks pair of shoes from china ---> International Distributor --> he sells it at 150 (to state distributor) ---> He sells it to District distributor at 300---- The shop keeper buys at 500 --> You are given MRP of 1000 (and attractive discounts... 20% off and 30% off).

This is how markets work....

[Payal108 in reply to roxboxfox]

Thanks Dr Sumeet for detailed reply.

This was not about which Radiation to choose. I was told to go for Tomo or IGRT, ( could not argue on technical so.. ) I insisted I can not afford and would like to go for IMRT. That still was not confirmed to me until planning was done.

Any way now on inquiry hospital insurance desk gave me figure of 190,000/- for IMRT. They may settle at less with particular TPA/Insurer later on that' different thing. Still 190000/- is less then 220,000/-

Shoes example does not seems to fit here .. as in this scenario you know what you are dealing with. But if same Bata shoe' MRP is manipulated on Flipkart and you are make to believe that you are getting great discount compared to show room, it more like that situation.

[sumeet_shah Administrator in reply to Payal108]

The people involved here in your situation is the insurance panel and the TPA desk designated by hospital. Insurance and other related issues are very time consuming at times; and in case of Radiation, it is purely managed by the people I mentioned above, the doctor is completely out of it.

So I suppose, there has been an unfortunate miscommunication by the concerned TPA person or the MSW (like you said) resulting into this. I do pray that you talk with them, sort it out and get your due which is very rightfully due to you.