I was getting Xolair injections once every 3 weeks at Dr. S's office. Dr. S is an allergist.
The price started out as $163. That's the price just for injecting Xolair - not for the Xolair drug itself. That's a lot. It's a little more work for the nurse than a simple injection, but not much.
But I was willing to pay $163 as a self-pay patient.
Then, without telling me they raised the price to $262 for self-pay patients. Pricing info is not available at his office. I got two Xolair injections at $262 that were in the same billing cycle before I found out about the increased price. So I was billed $198 extra.
I don't think this is fair. Three reasons:
- I should have been informed ahead of time of the price increase, especially since I get these injections repeatedly, on a schedule.
- The $262 price is far more than other allergists charge. I got quotes of $35, $115 and $179 from other local allergists. My family doctor used to give me Xolair injections for $65. And the allergist I'm currently using, includes an office visit with a PA and a brief checkup in their $115 price. Dr. S just had a nurse give me the injection.
- The allowed rate for a Xolair injection for a patient with BCBS insurance varied from $95 to $145. I know because I was briefly insured by BCBS.
So they are charging self-pay patients more than twice as much for the same service!
I repeatedly brought up the excessive charge with the doctor and told him my objections. But he didn't adjust the charge.
This seems like an unethical business practice. Perhaps not strictly illegal - but am I supposed to check the price each time before I get any service? I would be constantly bugging his billing office in that case. I didn't think they would increase the price by 60% without telling me, to much more than other doctors charge! I would like to work it out with Dr. S, since I liked his way of giving allergy shots. I complained to the BBB, maybe that will help.
I just found out that what Dr. S is doing is "upcoding" of the Xolair injections.
He charged the Xolair injections using CPT code 96401, which is for "Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic"
Sometimes this CPT code is used for Xolair injections, because Xolair is a monoclonal antibody.
But, many sources I found online, considered this code to be excessive for Xolair injections. Injections of other kinds of monoclonal antibodies are billed using this code, but a lot more work is required to administer those monoclonal antibodies.
Also, Xolair is not an anti-neoplastic (anti-cancer) drug, so this CPT code is often considered inappropriate for Xolair.
The preferred code to use for Xolair seems to be CPT 96372, which is for "Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular".
My allergist in NYC billed a Xolair injection using CPT 96372, and charged me $75 for it.
I'm currently getting Xolair injections at Dr. R's office. They use CPT 96401 for Xolair injections. But, they include an office visit with a PA and a thorough evaluation, before the injection - thus justifying the more expensive code.
Dr. S's billing for Xolair injections seems fraudulent. I wrote a letter to BCBS telling them about it.
Maybe I should report it to Medicare also. I'm not a Medicare patient, but Medicare might be interested, and they do audits of doctors' billing practices.