Insurance Strategies
WHAT YOU NEED TO KNOW
All Proton Centers have "Access Specialists or Intake Specialists" that will help you with your insurance approval. Sometimes it is best to let them take the initial lead as they deal with insurers daily and know the best tactics in obtaining approval. Follow their lead, but also read your plan and know your rights. Insurance companies can slow the approval process and delay necessary treatment so it is important that you get involved as soon as it may seem that your approval may not come through from the Intake Specialist or that your participation is needed in obtaining the approval. Keep in mind treatment will usually NOT BEGIN treatment planning phase until all insurance approval has been completed. Once again, time is of the essence!
Another important item to know is that many times, the insurance company will approve the case on a "case by case basis" or CONTRACT basis so they can control the costs. This means there will be a legal contract adopted between the health insurer and the proton center in terms of what is covered and at what rate. This contract can take several days to develop since they have to be billing code specific as mentioned above. An important thing to realize is each insurance company approves services using billing codes. You many not think this contract has any relevance for you, but when bills get denied due to billing code error it is usually because a difference exists between what was approved and what happened. For example, if your child was originally approved to have an echocardiogram during treatment as "out patient" versus "in patient" then that is a different billing code. Through treatment, you can usually log online with your insurer and follow your claim submission and status. Get involved early if you determine services are being denied due to billing code errors and have them resubmitted correctly.
Be sure to have the Intake Specialists review your costs in advance so you can prepare for your portion. Any delay in payment, can delay treatment, and you can't afford that to happen with your child.
Keep in mind the information presented here is not meant to replace your health plan’s benefit book. Read your health plan benefits book and learn your rights.
KEEP TRACK OF THE FOLLOWING:
Whenever you are dealing with an insurance company, it is advisable to take careful notes. Whether you have your treatment approved ahead of time or not, be sure you note the following:
- Document each and every phone call you make, as well as those made to you. Note the date, time, the phone number and department and be certain to get the name and position of anyone you talk to. If you ask for a name and the name is a “common” , like Cathy or Sue, get the last initial.
- Write down exactly what you asked and what you were advised. Notes might appear as the following:
3/23/11 4:00 p.m.- Called United HealthcareDepartment (document phone number). Spoke with Sue B. Advised proton treatment for pediatric cancer is eligible and will be covered 100%. $10 co-pay will apply. Asked if an approval letter will be sent. Sue B. said it should go out 3/25/11.
Documentation of this type is invaluable if coverage is denied at a later date. You also now have a date for follow up. If what you were promised is not received in a reasonable length of time, call back to verify all information you were given and verify when you will receive your letter.
- Keep copies of all written communication you send to the insurance company, hospitals, doctors and keep copies of anything sent to you.
No matter how frustrating the process seems, remember that anger, yelling, cursing, threatening and disrespect to those you speak with on the phone will not help get you the results you want. Customer Service Representatives are advised that they have the right to terminate a call if anyone becomes abusive on the phone. Keep yourself calm and use respectful language. If you are unhappy with the quality of information you are receiving, ask to speak with a supervisor.
OTHER
If your health plan advises you that proton treatment for pediatric cancer is “experimental”, inform them proton has been used clinically for 50 years and was approved by the FDA. Also, include that Medicare and Medicaid cover proton treatment and it’s important to note that those carriers normally do not cover any investigational or experimental treatments.
Occasionally a health plan will deny proton treatment for pediatric cancer saying surgery is more cost effective. Ask them to consider the long term total cost of having surgery- not just the hospital surgery and stay. The added cost of intensive post operative treatment which includes home supplies, multiple physicians’ visits, risk of infection, post operative complications due to invasive procedures and late effects all combined with the emotional impact which likely eclipses the cost of proton treatment.
The information provided is an overview and is by no means is a complete catalog of “how to”. There are many sites on this site's favorite links as well as others on the internet to help you. Your health plan’s benefit book will provide you with the requirements of your insurer. Also, appeal for your physician’s help and expertise.