Insurance Tips Help Pay for Cancer Care
Knowing Your Policy is Key to Getting Coverage
When it comes to paying for cancer treatment, the experts agree: it’s not as straightforward as it used to be.
Few patients can afford to fully pay their own way; the majority of patients rely largely on some form of medical insurance. Since policies and coverage vary widely, it pays for insured patients to do their homework, be familiar with the details of their insurance plan, and even to shop around for good coverage.
“Patients really need to become involved by understanding their insurance policy’s provisions and the non-covered charges,” says Jo Ann Flores, Manager of Financial Counseling in M. D. Anderson’s Patient Business Services (PBS) Department. The department handles customer service requests or patient billing issues, and its counselors often walk patients through the payment or insurance process. Although there is no typical cost of cancer care, medical bills can stretch into the hundreds of thousands of dollars, even for short, straightforward treatment.
Between them, Flores and PBS Associate Director Frank Norfleet have more than 25 years of experience helping patients navigate the financial waters of cancer care. They know that insurance coverage terms and related out-of-pocket expenses may affect treatment decisions, and vice versa. They offer the following suggestions for keeping afloat.
Become Intimate with Your Coverage
Whether insurance is through an HMO or some other type of managed care company, Norfleet says the best place to start after diagnosis is often with the patient’s employer or group benefits office. In his experience, patients often enter cancer care with the mistaken notion that their doctors or hospitals will take care of insurance situations, or that they can mediate with the insurer. The truth is, in today’s managed care environment, the onus is on the patient.
“It’s critical that patients understand what their benefits are,” Norfleet advises.
In contacting their benefits representatives, patients should be as specific and detailed as possible, and find out what kinds of treatment, drugs and procedures are covered. Particularly at specialty centers like M. D. Anderson, some of the newest treatment options may be considered experimental and therefore covered at reduced rates, or not at all. Patients also should stay in close contact with their insurance company and benefits office as their treatment plan evolves.
New authorization is often required for every new service or inpatient stay. “It’s a five-minute phone call, but it can mean the difference between you having to deal with a $100,000 payment, or your insurance company taking care of it for you,” Norfleet says.
Insurance Questions to Ask
How do I Deal with Diagnosis and Second Opinions? After being diagnosed, patients with primary care physicians may need a separate referral for treatment. In some cases, they will also need to contact their insurance company separately for authorization of care. Some insurance policies will allow patients to see a specialist without a referral.
Patients should always ask the cancer treatment provider what kind of insurance they accept. If a second or third opinion is sought, patients also should be aware that it’s their responsibility to go back to their insurance company to initiate approval for treatment. “Sometimes patients get lost in the system,” Flores says, because they think that process is automatic. In reality, she says, “it’s a two-step process.”
Which doctors and treatment centers are part of my insurance network? Patients who are part of an HMO must be clear which services and physicians are in their network, because out-of-network services basically revert to self-pay. Patients should not only ask about their oncologist, but also their pathologist, radiologist, anesthesiologist and any other physician who becomes involved in their care. “All of these people need to be in the patient’s health plan,” Norfleet says.
What medical services and locations are covered? At what level are they covered? With insurance plans that offer different levels of coverage, the difference between, say, an 80% coverage and a 60% coverage can add up greatly over the course of long-term treatment. Choosing a different laboratory for test results could make a big difference in the pocketbook. For that reason, Norfleet suggests asking about coverage for pharmacy prescriptions, lab work, chemotherapy, X-rays, radiation, and initial doctor’s and follow-up visits, as well as other specific treatments.
Are there any pre-existing conditions that my insurance plan won’t cover?
Patients also should ask about rules governing “pre-existing conditions.” While Medicare generally covers everything, other insurance plans may not cover treatment for certain conditions such as cancer. This is particularly true of plans that patients purchase individually, Norfleet says. Group or employer insurance plans will vary depending on the employer’s negotiation with the insurance carrier. In some cases, patients are able to get coverage if they have been with an insurance carrier a certain amount of time.
Who should I contact, and under what circumstances? Flores notes that some policies require patients to contact both the insurance company and the primary care physician each time a new service is used. If the patient doesn’t comply with this rule, or doesn’t know which services apply, the company can deny coverage or reduce payment – no questions asked. Patients play a vital role by understanding their responsibilities prior to services being rendered.
Shop Around
Once a patient knows what the cancer treatment plan will involve, and the patient understands his or her current medical coverage, it pays to shop around for the best insurance coverage, Norfleet says. He advises Medicare patients to compare the benefits offered in their HMO or other insurance plan versus traditional Medicare. Also, there are other options available, such as drug assistance programs and assistance through the Medicare savings program.
Annual enrollment periods or treatment considerations may preclude patients from switching plans right away, but certain insurance coverages may allow patients to save out-of-pocket expenses by choosing laboratory or pharmacy locations carefully.
Norfleet suggests that patients provide a copy of their treatment plan to both their HMO representative and their primary care physician. Then, they should go over the plan, item by item, and find out which services are covered where. A primary care physician may be able to provide chemotherapy in his office with less out-of-pocket expense, freeing patients to pay for specialty services only provided elsewhere.
Health Maintenance Organizations (HMOs)
HMOs are probably the most complicated insurance companies to deal with, Flores says, especially if patients want care outside of their managed care network. In rare circumstances, primary care physicians can advocate for a patient to receive out-of-network care. Often, however, some plans deny out-of-network care because they have the ability to render care within their own network.
Another option that many patients don’t know about, Norfleet says, is that people over age 65 always can drop their HMO coverage and opt for Medicare instead. The federal program pays less than most private insurance companies, but Norfleet says the price difference is worth it for some patients.
“The majority of patients are willing to accept that to get the care they want,” Norfleet says. Federal rules also allow patients to switch back to a regular HMO from Medicare with 30 days’ written notice.
Medicare Considerations
Most hospitals accept Medicare assignment, Norfleet says. On the other hand, Medicare doesn’t cover take-home medication. Again, the patient should pursue other drug assistance programs or Medicare supplemental coverage/plans.
Keep Detailed Records
One of the keys to staying above water in financing cancer care is to keep on top of paperwork. Norfleet suggests that the first thing patients do after being diagnosed is get two folders: one for inpatient services and one for outpatient services. “Every time you get a piece of paper, or make an agreement or phone call, put that information into one of those folders.”
The folders should include:
Records of authorization and referrals. Anytime something new happens in a patient’s treatment, he or she should make sure to get proper authorization from the insurance company, primary care physician, or both, prior to treatment. This includes hospital stays. Authorization can be obtained in writing or by phone, but patients should be sure to write down the date, name of the person spoken to, and what was agreed. Always request a copy of the authorization for your records.
Explanation of Benefits (EOB). “Short of an authorization or approval record, the EOB is the most important piece of documentation a patient can have,” Norfleet says. An EOB is issued by the insurance company each time a patient receives service. It outlines what services were received and when, which services the insurance company paid for, which the patient is responsible for, and why certain services may not have been covered fully. Norfleet and Flores urge patients to read their EOBs carefully as soon as they get them, because they often contain requests for information within a certain timeline. Also, if patients wish to dispute a payment, they often have only a certain number of days after receiving an EOB to appeal.
“A lot of patients set the EOBs aside,” Flores says, “and before you know it, their bills become really large. Then they’re harder to deal with.”
Keeping a journal or log also may be useful. “Six months into an extensive chemotherapy treatment, a patient may feel too sick to read the information or keep up with it,” Norfleet says. But if the system is in place, family members or caregivers can more readily take over.
The bottom line, Norfleet and Flores say, is to get organized early. Paying for care isn’t an easy thing to juggle on top of all the other concerns surrounding cancer treatment. But having a plan and being armed with information can help patients and their families stay on solid ground.
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