Insurance Tips for Calculating Treatment Costs

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:

  1. Do I need pre-authorization for my visit to the HTC in order to receive coverage?
  2. 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.

  1. 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.
  2. 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):
Hemophilia Specific

  • 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

Thrombosis Specific

  • 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
  1. What expenses get applied toward my deductible?
  2. 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.

  1. Where can I get factor?  Is there a specific specialty pharmacy I need to use?
  2. Are there only certain brands of factor covered and if so what are they?
  3. 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.

Additional Insurance Resources:

  • The National Hemophilia Foundation (NHF) has a Personal Health Insurance Toolkit which can help you figure this out. You can download a copy of the Toolkit by CLICKING HERE.  NHF Colorado also has printed booklet versions of these toolkits available to Chapter members at no charge. To request one, contact NHF Colorado at info@cohemo.org

Exchange Assistant Sites

  • In June of 2013, Connect for Health Colorado announced the network of organizations selected to provide in-person assistance to customers of Connect for Health Colorado.
  • The organizations comprise the Connect for Health Colorado Assistance Network. They serve local communities helping individuals, families and small employers consider health plan options, apply for insurance affordability programs, and sign up for health coverage.
  • The organizations all participated in a competitive selection process that awarded $17 million in grant funding, for the 18 – months that span the first two open enrollment periods for health coverage. These organizations demonstrated the understanding and ability to reach target populations as a trusted local resource, to provide application assistance, and the ability to conduct education and outreach.
  • The organizations have broad geographic reach and available resources to serve specific populations. Health Coverage Guides conduct outreach and education and provide unbiased in-person assistance with plan evaluation and the health coverage application process.

NHF Colorado is working to develop more resources to assist you and your family with this process.  You can also email your questions to us at info@cohemo.org

NHF Colorado Chapter

1385 S. Colorado Blvd. Suite 610
Denver, CO 80222
Office: (720) 626-1263
info@cohemo.org