Before Treatment: Handling Insurance Matters

It is important to have and keep good medical insurance. Many patients have private insurance through employee group plans or individual plans. There are several types of health insurance plans, so it’s important for patients to become familiar with their individual insurance plan and its provisions in order to know what they will have to pay for themselves.

Treating and managing most cancers is expensive. Some insurance plans provide for additional coverage under a “catastrophic illness” clause. These policies, which must be in place prior to diagnosis, cover major medical care needs and usually have higher deductibles with lower premiums. They are useful for people with chronic illnesses.

Some insurance policies pay a fixed amount for each day a person is hospitalized. There is usually a limit on the total number of hospital inpatient days that are covered in a calendar year. The money received from this type of policy can be used however a policy holder wishes. It is often used for the other expenses that families face when one member is ill.

[Affordable Care Act and Clinical Trials]

Keeping Records of Insurance and Medical Care

Keeping accurate records of medical bills, insurance claims and payments will help families manage their resources and reduce stress. Record-keeping is also important for those who wish to take advantage of the deductions available in filing itemized tax returns. The Internal Revenue Service (irs.gov) can provide information and free publications regarding tax exemptions for cancer treatment expenses.

KEEP RECORDS OF THE FOLLOWING:

> Medical bills from all healthcare providers

> Claims filed

> Reimbursements and explanations of benefits

> Dates, names and outcomes of contacts made with insurers and others

> Non-reimbursed or outstanding medical costs and copayments

> Meals, lodging and travel expenses, including gas

> Cellphone or telephone expenses related to medical or other types of care, including psychosocial

> Admissions, clinic visits, lab work, diagnostic tests, procedures and treatments

> Drugs given and prescriptions filled

SUGGESTIONS FOR RECORD-KEEPING:

> Decide who will be the record-keeper or how the task will be shared.

> Seek the help of a relative or friend. This may be especially important for people who live alone.

> Set up a file system in a file cabinet, drawer, box or three-ring notebook.

> Check all bills and explanations of benefits for accuracy.

> Review bills promptly after receiving them.

> Save and file all bills, payment receipts and canceled checks.

> Keep a daily log of events and expenses; a calendar with space for writing is useful.

> Maintain a list of phone numbers for cancer care team members and other contacts.

Handling a Claim Denial or Refusal to Cover a Prescribed Service

It is not unusual for particular claims to be denied or for insurers to say they will not cover a test, procedure or service ordered by a patient’s doctor. If this occurs, it is important to have a working relationship with a case manager who can discuss the situation.

First, patients should ask their doctors to write a letter explaining or justifying what has been done or has been requested. Then, patients should resubmit the claim with a copy of the denial letter and the doctor’s explanation. Sometimes the test or service only will need to be “coded” differently.

If challenging the denial in this way is not successful, then patients may need to:

> Postpone payment until the matter is resolved.

> Resubmit the claim and request a review.

> Ask to speak with a supervisor who may have authority to reverse a decision.

> Seek help from the consumer services division of the state insurance department or commission.

> Consider legal action.

Patients should make sure they keep originals of correspondence. Their record-keeping team may be able to help make copies. Also, patients should keep a record of dates, names and conversations they have about the denial.

Options for Those Who Are Uninsured

Patients who are not insured should consider these options when seeking coverage:

> Determine whether they can apply for group insurance through fraternal or professional organizations, such as those for retired people, teachers, social workers or real estate agents.

> Explore their eligibility for Medicare, which covers most people who are 65 or older, or who are permanently disabled and have been receiving Social Security benefits for two years.

> Since the enactment of the Patient Protection and Affordable Care Act, all states offer a Pre-existing Condition Insurance Plan (PCIP) that covers people who have not had insurance for six months or more and have cancer or another pre-existing condition.

Adapted with permission of the American Cancer Society