Insurance and Costs

Meet Dr. Syed Alam, MD, FACR

Double Board-Certified, Fellowship-Trained Rheumatologist · Musculoskeletal Ultrasound Trained · 10+ Years of Experience

Dr. Alam completed his rheumatology fellowship at Temple University Hospital after an internal medicine residency at John H. Stroger, Jr. Hospital. His clinical interests include rheumatoid arthritis, lupus, psoriatic arthritis, gout, Sjögren’s disease, osteoporosis and other rheumatic conditions.

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Plans we accept

PLACEHOLDER: this section must list the specific plans accepted, including the major commercial carriers, Medicare, any Medicare Advantage plans, and the practice position on Medicaid. State clearly for each whether the practice is in network or out of network, because that distinction affects what a patient pays far more than whether the plan is merely accepted.

Being listed on an insurer's directory is not the same as being in network for your particular plan, since carriers sell many products under one brand. The reliable check is to call the member services number on your card and give them the practice name and tax identification number, or to call our office and let us verify it for you.

PLACEHOLDER: confirm whether the practice verifies benefits before the first appointment as a matter of routine, and how the result is communicated to the patient.

Referrals and authorizations are different things

These two get confused constantly, and they are not the same. A referral is permission from your plan to see a specialist at all. A prior authorization is permission from your plan for a specific test or treatment. You can need one, both or neither.

Referrals

Preferred provider plans generally let you book a specialist directly. Health maintenance organisation plans usually require your primary care physician to issue a referral first, and many Medicare Advantage plans do the same. Referrals often carry an expiry date and a visit limit, so it is worth knowing both.

Prior authorization

Certain medications and imaging studies require the insurer to approve them before they are provided. In rheumatology this applies particularly to biologic and targeted synthetic treatments, and often to MRI. Our office submits the request with the clinical justification, and the insurer responds within a period set by the plan.

Approval is not automatic. Insurers frequently require step therapy, meaning they will fund a biologic only after cheaper treatments have been tried and documented as ineffective. That is a coverage rule rather than a clinical one, and where it conflicts with what you actually need, the appeal is part of our job.

Stock photograph. It does not depict this practice or any patient of it.

What you are likely to pay

Four terms account for most of the confusion, and they combine differently in every plan.

• Copay: a fixed amount per visit, often higher for a specialist than for primary care
• Deductible: what you pay yourself each year before the plan begins contributing
• Coinsurance: a percentage of the cost that remains yours after the deductible is met
• Out-of-pocket maximum: the ceiling, after which the plan covers the rest of the year

The practical consequence in rheumatology is that costs are heavily front-loaded into the early part of the calendar year, when deductibles reset. A patient on a stable biologic can pay a great deal in January and very little by June. Knowing that in advance makes it manageable; discovering it at the pharmacy counter does not.

Laboratory monitoring is billed separately

Most rheumatology treatments require regular blood tests, often monthly at first and then quarterly. These are usually billed by the laboratory rather than by the practice, which means a separate bill and sometimes separate network rules. Check that the laboratory used is in network as well as the practice, because the two are not always the same.

PLACEHOLDER: state which laboratory the practice uses, whether it is in network with the main local plans, and the self-pay charge for a new-patient and follow-up consultation.

Specialty pharmacy and biologic medicines

Biologic treatments for rheumatoid arthritis, psoriatic arthritis, lupus and axial spondyloarthritis are not dispensed at an ordinary pharmacy counter. They are handled by specialty pharmacies, which usually deliver to your home on a schedule and require the prescription to be routed through your plan pharmacy benefit rather than its medical benefit.

This adds steps. Expect the specialty pharmacy to call you to arrange the first delivery, to require refrigerated storage for most injectable biologics, and to need a repeat authorization periodically, typically once a year.

Manufacturer copay assistance

Most biologic manufacturers run copay assistance programmes that can reduce the monthly cost substantially for patients with commercial insurance. They are worth asking about, and our office can point you to the relevant one.

There is an important restriction. Federal law prohibits manufacturer copay cards from being used by patients with government insurance, which includes Medicare, Medicare Advantage, Medicaid and TRICARE. If you are on any of those, the route is different: independent charitable foundations run grant programmes for specific diseases, and eligibility depends on income and on whether the fund is open at the time you apply.

PLACEHOLDER: confirm whether the practice has staff who assist with copay programmes and foundation applications, and name the contact.

If you do not have insurance

Being uninsured does not make rheumatology unaffordable in every case, though it does change the sequence. The main costs are the consultation, the laboratory work and any medication. The first two are predictable and can be quoted in advance.

Several of the most effective rheumatology treatments are also among the cheapest. Methotrexate, hydroxychloroquine, sulfasalazine, allopurinol and prednisone are all long-established generics, and for a substantial proportion of patients they are what is actually needed. The expensive medicines are not the first line.

PLACEHOLDER: state the self-pay charge for a new-patient consultation and a follow-up, whether a discount is offered for payment at the time of service, and whether a payment plan is available.

Questions worth asking your insurer

Five minutes with the member services number on your card answers most of what matters. Have the plan name and member number in front of you and ask these directly.

• Do I need a referral to see a rheumatologist, and does one expire?
• Is this practice in network for my specific plan, not just my carrier?
• What is my specialist copay, and how much of my deductible remains this year?
• Which laboratory is in network for my blood tests?
• Does my plan require prior authorization for biologic medicines, and does it require step therapy first?
• Which specialty pharmacy does my plan require me to use?

Write down the date, the name of the person you spoke to and any reference number. Insurers keep call records, and a reference number resolves a disputed answer in minutes rather than weeks.

PLACEHOLDER: this page must be completed by the practice manager or billing lead before launch. List every plan accepted and whether the practice is in network, state the self-pay position and typical charges, confirm the cancellation policy, and confirm who patients contact with a billing question. Nothing on this page should go live as a general description where a specific answer is possible.