As much fun as having your liver eaten by an eagle every day

Prometheus Labs offers some rather expensive laboratory tests, most of which are only available from Prometheus. The blood is drawn anywhere, shipped to Prometheus in California, and the results are sent to the ordering physician.

The pricing is pretty arbitrary. The first time that Prometheus does a remicade trough level for a patient, they bill $2500. After the first time, it’s just $375. There’s absolutely no justification for this sort of price difference.

Prometheus is not in network for most insurance plans. It’s not clear if they are in network for any insurance plans. They do participate in multiplan, which can reduce the bill by 10% if your insurance plan has a deal with multiplan. Prometheus does bill insurance plans, and they file appeals on (some) larger bills, but they don’t generally count on insurance companies paying them.

Our insurance has denied Prometheus claims, saying at various times that they are not medically necessary, not preapproved, or out of network. The denials are arbitrary, and we’ve been able to appeal them to have them processed either as out of network, or even processed as in network based on the lack of an in network provider who can offer these tests. The appeals process is also arbitrary and can take months (the longest so far took close to 2 years). When we tried getting a prior authorization for a Prometheus test, the insurance company waited over 3 months to give a reply, and then denied the prior authorization. In the meantime, they had already approved the actual claim for the Prometheus test. Left hand, right hand, miles apart.

If your insurance does not pay, then Prometheus will offer to reduce the bill to $250, or possibly less if your income is low enough. This can be a great deal on the first remicade trough level if your insurance applies the $2500 (or $2250 with multiplan discount) to your deductible on a high deductible plan, but you only have to pay $250 at most. Even with a $375 bill reduced to $250, you can save a little bit on your deductible. The same logic applies if you’re likely to hit your out of pocket maximum for the year. It can get complicated with in network and out of network cross-accumulations, which are very dependent on your particular insurance plan. We now know ours much better than we used to.

After years of struggling to understand how to navigate all of this, we discovered that Prometheus has a deal with a few of the thousands of third party labs and hospitals that can draw the blood to have the third party do the billing. The third party pays Prometheus and bills your insurance. If the third party is in network, all of a sudden there’s no more arguments with the insurance plan (at least in our experience). And bizarrely, it can be much less expensive than the direct billing from Prometheus, even with the discounts that Prometheus offers for moderate income patients. For one recent test, the options were $270 from insurance to Prometheus, $250 from us to Prometheus, or $100 from us to the third party (with an unknown amount going to Prometheus out of that). Quest, that wondrous nationwide megalab agglomeration, can draw blood and ship it to Prometheus and bill the insurance plan for the test as Quest, but only from some regions of the country. Ours is not such a region.

Why does Prometheus charge $2500 or $375 for the same test at different times? Why does both a $2500 test and a $270 test get reduced to the same $250 for an individual paying the claim? Why does Prometheus accept $100 or less as full payment from a third party lab, while they demand far more from an individual even if the individual offers to pay in advance? And since their prices are completely arbitrary, why not let the patient request a higher bill to the insurance company if that will help the patient?

Depending on the details of your plan and where you are personally in your plan year, you might be better off paying a $100 in-network bill, or you might be better off paying $250 while having your in network or out of network deductible reduced by a higher amount. This isn’t a path towards rational or transparent pricing for health care. It’s not even a path towards giving patients an incentive to choose the lowest price.