Insurance Tips for Calculation Treatment Cost
Compiled by HTC social worker, Audra Leblanc:
Often times, there are additional fees associated with your clinic visit besides your co-payment, and these charges are not always clear just by looking at your summary of benefits. It is important to contact your insurance company prior to your clinic visit to identify other possible charges. For example, lab work is usually not included in your co-pay and there may be a facility fee that is not included either. Given our experience and understanding of how complicated it can be to navigate the insurance world, we created the following list of questions for you to consider when talking with your insurance provider.
Questions to ask your insurance provider:
- Do I need pre-authorization for my visit to the HTC in order to receive coverage?
- If I get a pre-authorization to be seen at the HTC, how will my insurance coverage be applied?
Please Note: We have encountered situations where patients received authorized by their insurance to get labs done at the HTC because they couldn’t be done by their in-network provider. These patients were later charged for the labs because they were done out-of-network. Therefore, authorization is not a guarantee of coverage.
- In addition to my co-pay, are there other fees I can expect to be charged? For example, a facility fee, a separate physician fee, etc.
- What can I expect to pay for labs? Keep in mind that many plans require you to meet your deductible before labs are covered. Also, labs are optional. Please talk with your provider to discuss financial concerns and determine what labs are necessary at this time and the reasoning.
Here is a list of labs that we typically draw and the associated CPT codes (You can share these with your insurance provider to get a more accurate quote):
- Factor Inhibitor – 85335
- CBC – 85025, 85027, or 85004
- Comprehensive metabolic panel – 80053
- Factor VIII Activity – 85240
Note: 4-6 measurements of these make up a half life and recovery study, which is a test we sometimes do to see how long factor stays in one’s system.
- Factor IX Assay – 85250
- 25 Hydroxy Vit D – 82306
- Von Willebrand Antigen – 85246
- Von Willebrand Activity-Ristocetin – 85245
- Von Willebrand Factor Multimer – 85247
- Blood Type (ABO/Rh) – 86900/86901
- Protein C, Functional – 85303
- Protein S (free) – 85306
- Antithrombin – 85300
- dRVVT (dilute Russell Viper Veriom) – 85613
- ACA (anticardiolipin antibody) IgG & IgM – 86147×3
- Beta 2 glycoprotein I antibody, IgG, IgM, IgA – 86146×3
- PT/INR – 85610
- DDimer – 85378
- Factor VIII Assay – 85240
- Factor V Leiden (DNA) – 83891, 83896×2, 83898, 83912
- Prothrombin Mutation 20210 (DNA) – 83891, 83896×2, 83898, 83912
- Lipoprotein (a) – 83695
- Homocysteine – 83090
- What expenses get applied toward my deductible?
- How is Factor covered?
Please Note: Factor is most often covered under major medical, so if you talking with an insurance rep who can’t find factor information under prescription coverage ask them to check under major medical.
- Where can I get factor? Is there a specific specialty pharmacy I need to use?
- Are there only certain brands of factor covered and if so what are they?
- Ask about your coverage for imaging. We sometimes recommend imaging to assess joints and bleeding.
After speaking with your insurance provider, consider asking them to provide some verification of your conversation so you can reference it in the future if needed.