Insurance Coverage and Financial Basics For Cancer
A Primer for Patients and Caregivers
As you face a cancer diagnosis , as either a patient or a caregiver, you will want to be sure that you know the facts about the applicable insurance plan and the financial realities of treatment. An organized system for managing this aspect of cancer care can clarify the issues and ease the burden. By educating yourself about insurance benefits and keeping organized financial records, you can prevent financial dilemmas and avoid unnecessary stress. It can be helpful to use three-ring binders or filing systems to organize healthcare records and financial information. If you're the patient, consider designating a caregiver or family member to keep track of this information.
Patients Who Don't Have Insurance
If you're not covered by an insurance plan, you may find it worthwhile to investigate other sources of financial aid. Patients who have not yet received any treatment may qualify for Medicaid or Family Health Plus. Because Medicaid is a state-managed program, the eligibility criteria may vary. Family Health Plus is comprehensive insurance offered by some states at no cost to lower-income families without health insurance who are not eligible for Medicaid. Most oncology clinics and social services departments at local hospitals will have applications for these programs and designated individuals to help patients with the process. If you're already in treatment, ask your healthcare provider to suggest some options.
Insurance
Prior to beginning treatment, cancer patients need to determine what type of insurance they have and what will be covered by their insurance. There are three types of insurance:
- Traditional Indemnity Insurance: Traditional indemnity insurance is sometimes referred to as "fee for service." This type of insurance plan allows patients to go to any doctor or hospital that they select, anywhere in the United States or abroad. Although insurance plans will vary, patients will generally be responsible for a deductible and copayments.
- Health Maintenance Organization (HMO): HMOs vary greatly, but they are essentially organizations that contract with large numbers of patients to achieve a volume discount on healthcare costs. With an HMO, patients are assigned a primary care physician who manages their care and refers them to specialists within the plan when necessary. The patient (or employer) pays a fixed annual premium, which is generally less costly than an indemnity plan premium.
- Preferred Provider Organization (PPO): A PPO allows patients to see a doctor from the plan's network of physicians for a small copayment fee. Patients who choose to see a doctor out of the network must pay the balance between the PPOs scheduled fee and the billed amount.
- Is pre-authorization required for some surgical procedures or treatments? If so, how does this process work?
- Does the coverage have any exclusions, items or services for which benefits are not provided? (For example, some plans do not cover the expensive growth factors often required to replace blood cells depleted by chemotherapy.)
- Are second opinions covered?
- Are second opinions required for certain procedures, such as surgery?
- Does the plan have a maximum calendar-year out-of-pocket expenditure? (For example, with some plans, once a patient has paid $3,000 in deductibles and copayments, the insurance plan provides full coverage of the balance.)
Payment and Billing Procedures:
Billing procedures may vary depending on where a patient receives treatment. Patients should follow this procedure carefully to ensure that they are receiving their full benefits. Keeping thorough records will ensure that all bills are paid by the appropriate party.
Hospital/Clinic/Hospital-affiliated Doctor's Office: Typically, if any member of the healthcare team is in practice within a hospital, then the hospital billing department will bill the insurance company directly. Once the insurance company has paid their portion, the hospital will then bill the patient for any balance due.
Private Office or Specialist: Doctors who treat patients in their own offices have different billing practices, which will vary from office to office. Some doctors will bill the insurance company, as a hospital would. However, other doctors require payment from the patient when services are rendered. In this case, the patient is then responsible for sending the receipt to the insurance company for reimbursement.
Copayment: A copayment is the portion of covered medical costs that is paid by the patient. In a typical plan, the patient's copayment may be based on a percentage or a flat fee. Usually, the copayment is due at the time of service.
Filing Insurance Claims: Many cancer patients do not take full advantage of their insurance plans. This may occur because they aren't aware of their benefits or are confused and overwhelmed by the paperwork. Patients should file claims for all treatment. Sometimes a family member can assist with this task. If the patient or family needs help, a social worker can often provide assistance as well. Some community organizations and private companies also offer help with filing insurance claims.
Appealing Denied Coverage: Some claims may be rejected or reimbursed at a reduced level. There are many reasons for claim rejection. However, patients can usually appeal a refused claim or reduced payment. Following are five steps for appealing a rejected claim:
- Phone the Insurance Company: Immediately phone the insurance company to inquire about the rejected claim. Sometimes, the rejection is simply a result of a clerical error, such as an incorrect code or a misstated date of service. In such cases, the situation can be remedied by simply filing a corrected claim.
- Appeal by Phone: Sometimes coverage is denied for something that is not excluded in the policy. In these cases, patients can sometimes request via the phone that their claim be reviewed.
- Appeal by Mail: If a phone request is refused, patients can write a letter to the insurance company stating why the procedure should be covered. In such cases, it is important to enclose a copy of the denial notification. In addition, patients may wish to have their doctor write a letter explaining why the service meets the requirements for coverage.
- Write to the State Insurance Commissioner: Some patients may consider sending a duplicate of their appeal letter to the state insurance commissioner. Patients who choose to do this can include a brief cover letter explaining their problem and asking for assistance in resolving the issue.
- Request Physician Review: Sometimes, patients can request to have their claim and case reviewed by a physician with the same specialty as the doctor who ordered the treatment or procedure. In addition, they may request a copy of the specific statement from the policy or the benefits booklet that explains why coverage is being denied or paid at a reduced level.
The unwelcome pressure of cancer-related insurance and financial issues can be reduced when patients understand their insurance, establish avenues of appeal and are organized prior to receiving treatment. By being informed, educated and having a support network, patients can minimize stress and focus on successful treatment and recovery.
