Cancer and Your Insurance: Watch Out for the “Gotchas”

Being diagnosed with cancer can be overwhelming. Figuring out your insurance coverage can bring added stress at a time when you need to focus on treatment.

Ten valuable tips to empower yourself:

  1. Read the fine print to learn your benefits – in detail. What is covered: surgery, outpatient infusion therapy, is chemo considered medical care or prescription drugs? If you have short term or catastrophic insurance, are there exclusions or waiting periods?
  2. Register online with your health plan to access the documents you’ve buried or thrown out, plus see your claims as soon as they have been paid. Most health plans also have smartphone apps.
  3. Request a case manager from your health plan to help you navigate the system – it’s free.
  4. You may quickly reach your annual deductible, along with your maximum out-of-pocket costs; monitor your payments. Providers won’t necessarily know when to stop charging co-payments; this is your responsibility to monitor. Explanation of benefits (EOB) statements you receive (or access online) will state when you have reached these amounts.
  5. Be prepared that out-of-network providers can generate huge bills. Do your research to learn where to get the best care, locally as well as nationally or even abroad. Then evaluate if you are willing to pay cash in case your health plan doesn’t allow out-of-network services.
  6. Most insurers allow at least one second opinion, sometimes more, as long as the visit is pre-approved. Make sure to your records are sent over to the consulting provider, or bring copies. Online portals have visit summaries; you may have to order a CD to be picked up at a hospital.
  7. Your health plan may allow out-of-network consultation – typically only for an office visit where your records are reviewed, not for treatment. If you are fortunate enough to get an outside referral approved, determine which services are included. Lab testing by blood draw may be fine but “advanced” imaging such as MRIs and CT scans may be excluded. Keep in mind that most testing can be done in-network, it’s the interpretation of the data where you need the best expertise you can find.
  8. If your request or claim is denied, file an appeal. There are 3 levels of medical or administrative review: internal physicians paid by the health plan (internal review), outside peer specialists (external review) and State Insurance Department consultants (independent review). Writing an effective appeal letter can be hard. Hire an advocate or ask friends to read your letter to make it’s focused on medical necessity and make sure the tone is not overly emotional.
  9. Use a patient advocate to ease your burden. Advocates can suggest resources, investigate clinical trials, escort you to appointments, scrutinize claims, manage paperwork, prepare appeals and serve as your trusted representative. Make sure the advocate sends in a privacy release form to get authorized access with your health plan and providers.
  10. Social media and cancer support websites (CancerCompass, OncoLink, CancerCare, Facebook) can be a great way to find out how others are handling complicated or chronic illness.

Planning ahead will facilitate peace of mind during a chaotic time. Document your questions, keep records and push back when necessary to get the best care and insurance coverage possible!

Thanks to Cancer Champions for sharing this post on their blog.

Contact me to discuss your needs.

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