Tips for Insurance Approval
TIPS FOR GAINING APPROVAL FOR PROTON THERAPY
- A good first step is to have your referring pediatric oncologist to clearly indicate in the letter of referral that he/she strongly recommends (or words to that effect) proton therapy. Even better is getting the oncologist to directly refer you to the proton center of your choice (see our tab on proton centers).
- Get a “letter of medical necessity” from your oncologist or one of the doctors at a proton center. Suggest a "plan of care" document if the insurance company gives early indication of nonapproval.
- It is also suggested getting the employer involved (who offers the insurance plan) because many plans are now self-funded meaning the employer writes the plan and the insurance company simply administers the benefits. If the employer writes the plan then they may have the right to make an exception to any benefit.
- Try to get names of one or more earlier patients who were covered by your provider for this procedure at the proton center you are seeking to go to. This will substantially strengthen your case. If you’ve already been accepted for treatment at a proton center, your case manager can assist you in obtaining this information.
- Call the appeals center for your state to find out what is needed for an adequate appeal.
- You can switch from a HMO plan to a PPO plan with the same provider (e.g., Anthem/Blue Cross) if coverage is an issue with the HMO. The best time to make the change is during “open season” or at policy renewal time. Premium costs are greater, and the co-pay fees may be different, but the trade-offs should be well worth it. Freedom to choose a doctor as well as freedom to seek tests of choice, regardless of whether the desired test may cost slightly more than some other test, are advantages of a PPO. And after one’s health situation is taken care of, one can always switch back to an HMO but it is recommended to stay with the PPO plan in case there may be any further complications that may arise at a later time and your child needs to go out of the network again for any other specialty doctors.
- Another approach is to switch insurance companies to a provider that is known for approving proton therapy, being careful NOT to cancel your original coverage until the new coverage is in effect. It also helps to have the oncologist or primary care physician write a letter stating this kind of treatment is in the best interest of your child’s health and they recommend it.
MAKE SURE YOU READ ALL OUR TABS HERE ON INSURANCE.