Patient Insurance Strategies

Receiving a cancer diagnosis can be a challenging time. Learning a health insurance plan has denied coverage for the treatment plan a cancer patient and their physician have determined is most appropriate for them is a challenge most never expect to face. A denial once a patient has a treatment plan in place puts an additional emotional and physical burden on patients and their families. Fortunately, our proton therapy center members partner with cancer patients to face this challenge by taking a proactive approach to appealing these denials. Cancer patients can also advocate on their own behalf to overturn these denials. Below is a step-by-step guide on what to do if a cancer patient receives a coverage denial for proton therapy from their health insurance plan.

Please note that before starting the appeal process, speak with the financial counselor or billing office representative of the treatment facility selected so they can further explain the process and offer support.

Thousands of people diagnosed with cancer have successfully appealed their health insurance plan’s denial for proton therapy coverage, and there is a good chance that others will be able to do it as well. Navigating the appeals process can be both daunting and frustrating for cancer patients and their families. When walking through this sometimes lengthy process, keep in mind that winning an appeal takes patience, persistence and a good understanding of why proton therapy is a viable treatment option. This guide provides various tips and strategies to help cancer patients strengthen their case.

male doctor and female nurse talking to male patient

STEP 1 - FACTS

Cancer patients and their families often experience anger, fear, and confusion upon receiving a denial from their health insurance plan. Their first response is often to contact their health insurance plan immediately upon receiving the denial which is not recommended. Instead, cancer patients and their families should carefully review the details of their health insurance coverage policy and the specifics of the health insurer’s appeals process.

Cancer patients should know the following;

The steps required to file an appeal – these actions must be followed exactly in order to overturn a denial.
How many levels of appeals the health insurance plan allows – this is usually found in the health insurer’s benefits handbook or what is called often called the Summary Plan Description.
The type of health insurance plan they are participating in (HMO, PPO, High-Deductible, HRA, Indemnity, Medicare or Medicare Supplement)
The length of time the health insurer has to review an appeal – typically health insurers use the full 30 to 60 days they are allowed.
If the health insurance plan is funded by an employer and the health insurer is the administrator of the plan. The employer in these cases can decide to request an Administrative Waiver resulting in overturning a denial.
The reason the coverage was denied by the health insurer – this should be provided in writing.

STEP 2 - SEEK SUPPORT

Physician Partners

Written input from a physician can be a valuable resource when appealing a denial. Physicians at the proton therapy facility selected can help provide important medical documentation. This is often referred to as a “Letter of Medical Necessity” and explains in detail why proton therapy is the most appropriate treatment available for a cancer patient’s specific condition.

Legal Representation

Cancer patients uncomfortable with the appeals process sometimes seek the legal services of an attorney. Some attorneys specialize in handling insurance coverage denial appeals and this can be an advantage for cancer patients and their families. Attorneys know the individual state laws concerning health insurance denial appeals and can assure that the health insurers follow their own rules as well as the state’s laws. Health insurers will also take the denial appeal more seriously once an attorney has been hired.

male working with a tablet and computer at a table

STEP 3 - RESEARCH & IDENTIFY SUPPORTING INFORMATION

In addition to identifying the facts and seeking support before contacting the health insurer, it is just as important for cancer patients to perform their own medical research to support their appeal. Valuable information can be gathered from various cancer advocacy groups and organizations, books, and respected internet websites. If information identified by a cancer patient or their family includes medical terminology they do not understand or the relevance of to their diagnosis and treatment, please discuss with a member of the medical team at the proton therapy facility selected.

Additional beneficial information cancer patients should try to obtain

Written documentation the health insurer used as the basis for their decision to deny coverage (proton therapy coverage policy, medical literature, etc.). The patient can request this information for the insurance company and the health insurer is legally obligated to provide it.
Any available legal cases that are similar to the cancer patient’s situation. It is much more difficult for health insurers to deny coverage of a legal precedence has been set. It is possible in this situation that the health insurer has changed their coverage policy since the legal case was determined.

female taking notes on a notepad at a desk

STEP 4 - DOCUMENT & MAINTAIN RECORDS

Once communication with the health insurer begins it is extremely important to document every interaction. This includes the phone numbers called, the person spoken with, and a synopsis of the conversation.

Patients should:

Keep a record of every phone call made and received. Document the date, time, phone number, department, and full name and position of the health insurer representative.
Document the conversation including questions asked and answers received. This information can be important later in the appeals process.
Maintain copies of any written communication sent to the health insurer, healthcare provider, or physician as well as any written documentation received.
During conversations with the health insurer, remain calm and respectful even if frustrated with the representative on the call. If a representative believes someone is abusive on the call, they have the right to terminate the call. If the representative is not helpful or responsive on the call, request to speak to a supervisor or manager.

STEP 5 - WRITE A PROFESSIONAL APPEAL LETTER

Once the steps above have been completed, cancer patients can write a professional letter to formally request an appeal of the coverage denial. When writing an appeal letter all items required by the health insurer’s appeal process must be included with supporting documentation.

Items that should be including in an appeal letter

The reason why the patient and the physician have determined that proton therapy is the most appropriate treatment for the patient’s specific diagnosis.
Patient’s medical history including any exacerbating conditions including prior cancer diagnoses, previous surgeries, heart and lung conditions, diabetes, etc. These conditions may help overcome a “not medically necessary” reason for the initial denial.
Include any emotional or non-medical issues that may develop from other types of treatment.
Note the increased costs related to treating side effects from other types of treatment including long-term medical supplies, medical devices, psychological issues and in-home nursing care.
The intent of the cancer patient to pursue every available option to them to overturn this inappropriate coverage denial including independent external review and legal representation.
Letters should be addressed to a specific individual in the appeals department and be sent via certified mail.

OTHER USEFUL TIPS

Keep this following in mind when filing an appeal

Avoid verbal appeals as they do not provide new information to the health insurer.
Anything shared verbally must also be included in written communication.
Receiving an approval for a consultation with a proton therapy physician does indicate that proton therapy treatment is approved.
Assure that all steps in the appeals process are not bypassed.
Cancer patients have the right to ask for the rationale used by the health insurer to determine a denial of coverage.
Continue to follow-up with the health insurer through all levels of appeal even if continued denials are received.
If all levels of appeal are still denied, speak with the proton therapy facility financial counselor or billing representative about the following options;
- requesting an Independent Review Board review the case
- filing a complaint with the State Insurance Commissioner
- hiring an attorney
Contact the local State Representative or Senator who may have influence with some insurance companies.
Proton Therapy was approved by the FDA in 1988 and most cancer diagnoses have been covered by Medicare since 1997.

Portrait of happy smiling female patient and doctor at office. Focus on woman.

AFTER A SUCCESSFUL APPEAL

If a patient receives an approval for their treatment after an appeal, make sure that the costs are covered at the rate described in their plan. If it is discovered that this is not the case, this will need to be appealed as well. Keep a copy of the appeal approval letter. While this information should exist in the health plan’s computer system, unnecessary delays can be avoided by having a copy of the approval letter ready to provide upon request.

*Contributor/Source: The University of Pennsylvania Department of Radiation Oncology Patient Advocacy Brochure