Cost of Being in a Clinical Trial

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Topics include: Living Well

Dr. Sagar Lonial, myeloma expert, gives an overview of how a clinical trial is billed. The insurance company is billed if the treatment of care falls under what is considered to be standard. However, if the treatment is not considered to be standard, the clinical trial itself is billed.

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Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Andrew Schorr:

Dr. Lonial, I want to talk about cost a little bit.  When somebody is in a clinical trial, I understand that the medicine that’s being studied, that there’s not a cost to that.  Help us understand cost and being in a clinical trial. 

Dr. Lonial:

I think in the last few years there’s been a lot more scrutiny of how clinical trials are billed and how things occur in terms of what is standard, what is not standard, and how that all gets filtered out to patients.  And I think nationally there’s a little bit more uniformity about how some of this is done. 

We have a group of people that essentially develop our budgets for clinical trials, and they look at everything that is in a clinical trial, from drawing a CBC to doing a history and physical, to getting an echo, all those things that are often parts of clinical trials.  And they look at that list and they say, for a patient with myeloma at this stage in their disease, is this something that Medicare would pay for, and if the answer is yes, then it gets billed to insurance.  If the answer is no, then it gets billed to directly to the study. 

Things that are not considered standard of care do not get billed to the insurance company because that would be potentially fraud.  That would be Medicare fraud.  But things that are specific to the study do not get billed to the insurance.  They get billed to the clinical trial itself.  And when you do it that way I found very little resistance from most payers to putting patients on trials.  I won’t say never because you can never find an insurance company that does what we want them to do, right?  But in general you can usually have an argument with somebody if that’s how you break out the budget. 

Andrew Schorr:

And Medicare being the biggest payer for a lot of people here, what about Medicare’s position on the trial? 

Dr. Lonial:

Again, as long as you’re not billing nonstandard of care things to Medicare they’re okay with it. 

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

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Page last updated on December 26, 2013