TPMT Testing Prometheus????

Your contracted lab should draw the blood and then follow their procedures for transporting samples to send your blood/tissue to Prometheus.

I have had Prometheus tests before, I think for both diagnosis and for 6MP levels (I've been on 6MP for several years), and have never dealt w/ Prometheus themselves. I go to my lab and they send the sample, Prometheus tests it and then sends the results back to my GI/HMO.

Do you have an HMO or PPO? If your HMO GI is asking for these tests (which HAVE to be done to be on 6MP), then they should direct you to where you need to go to have it be covered at your copay/deductible ONLY. Call your GI and tell them you have an HMO (assuming this GI is a contracted HMO provider) and ask them for both a lab slip/order and the location of your lab.

If you have a PPO, then you should contact BCBS and ask what lab is in network (so you can have the tests covered at the lowest out of pocket costs) for you and then contact the lab and ask if they are able to get the test to where it needs to go. The Prometheus website states that they coordinate with many outside labs to get the tests to them. http://www.prometheuslabs.com/Patients/InsuranceAndBilling.aspx

AFAIK, there is NO reason a lab should come to you- it's convenient, sure, but you will defiinitely pay for that convenience. Feel free to email me if you have any questions.

Thanks for the feedback! I have PPO and I don't think my usual lab (quest diagnostics) administers the blood test. I just called Prometheus they said they do not charge for the home blood draw. I guess I may have to hope for the best and schedule the blood draw. I really want to start my new meds and have been prolonging because of this.

Thanks again!

I agree w Gumby. Because you have a PPO, YOU have to do your own care coordination (as opposed to your PCP/Medical Group doing it for you like in an HMO), but that doesn't mean you're SOL when it comes to coverage of less common services, you just have to do some extra work.

Quest may not provide the testing and analysis you need, (Prometheus provides some less-common and even proprietary diagnostics) but Quest IS able to draw your blood and send it to Prometheus for you. Drawing blood and transporting it to where it needs to go is an essential function of a lab. Again, Quest SHOULD be able to do all the work you need. If Quest tells you they cannot do that (which they may, depending on a multitude of factors), you should contact BCBS and ask them where you can go. IF BCBS is unable to provide you with an in-network lab (meaning you will incur the lowest tier of out of pocket costs) who can do they work of being the middle man between you and Prometheus, then their network is potentially inadequate and they should provide you with an out of network lab who can do the services and you should only be charged your in-network copays/deductible. Insurance companies should not be allowed to have an inadequate network and then punish the patient for it.

But I'll get off my soapbox and try to tell you exactly what to do. When you call BCBS, note the date, time, and ask for a name and/or employee ID# of the person you speak with. You can also ask that they email/mail hard copies of info to you, if you do have to go to a non-network (outside the BCBS contracted provider netword) lab, you can ask for a pre-authorization and get approval to go out of network. $900 is a lot of money that most people don't have at the ready, I wouldn't just hope for the best in this situation.

There are things you can (and should) do to minimize your liability. Also, you should be calling your GI (if he's a BCBS provider) and BCBS for help with this because your contract for insurance coverage is with BCBS, not Prometheus. I would hope that Prometheus would not purposely give you bad advice in order to increase the amount of money they can make off you, but they don't know your coverage and cannot/should not speak to what you have to do in order to get the services covered. In other words, they may not know that coming to your house for a blood draw wouldn't be covered (it's not their responsibility to know, it's yours) but will tell you that's how it's done because that's a service they offer.

Seriously, it's much easier to get everything pre-approved then it is to obtain reto-authorization.

exit 4- sometimes it pays to appeal, sometimes not. There are many factors involved with why services with an outside provider wouldn't be covered and a lot of those of factors involve state-specific laws. I live in CA and we tend to have very consumer-friendly laws re heath insurance (probably in other areas, too) so I could help you more if you were in CA, but you might check with your State's homepage (for example, CA.gov or just google your state) to see if there is a Department of Insurance which regulates health insurance products in your state.

Frequently, the letters/paperwork received from the health plan have information on them for additional appeals/review. This is something you may want to ask about- couldn't hurt, especially since your doctor felt the test was necessary. If there isn't a state department that can help, or additional appeals fail- your best bet is to do what you are doing, which is to negotiate the cost w/ the provider. This can be unrealiable, however, because any deal they may be willing to make for you, may not be given to anyone else. Meaning just because you are only going to owe $200 for the test, doesn't mean that's all OP may be billed. Anyway, I hope you are able to find a way to further appeal the costs.

Hi Youretoomuch,
Just to clarify, Prometheus lab is still the one who does the actual testing. What you are needing from BCBS is to approve the test in advance so you know you are covered. The BCBS rep can tell you whether they will approve a Prometheus lab person coming to your house, or give you directions as to how to get the proper order so you can go to your local lab and have it sent to them. You can ask to speak to a case manager if the regular rep can't help you. I know it is a confusing hassle...just trying to save you some money!