Health Insurance
Dealing With Your Health Insurance Company
Undergoing treatment for lung cancer is demanding enough without having to deal with your health insurance company at the same time. That's why it’s a good idea to ask someone close to you to assist you with your health insurance issues during treatment. Designate yourself or a caregiver to keep track of all your healthcare information.
The following topics will help you get organized and acquaint you with the basics of health insurance.
Insurance Considerations: Basic Questions
What Kind of Insurance Do I Have?
Learn What Your Coverage Includes Before Beginning Treatment
Payment and Billing Procedures
Get Organized! Get All Your Paperwork Together and Keep It in One Place
File Claims for All Covered Costs
When Coverage Is Denied
Get a Case Manager on Your Case
The Patient Advocate Foundation
If You Don’t Have Insurance
Help From the Federal Government
Sources of Information
Additional Resources
Insurance Considerations: Basic Questions
Ask yourself these questions:
- Which health insurance provider do I have?
- Is treatment for lung cancer covered under my insurance policy?
- Who will be my healthcare team?
- At which clinic or hospital will I be treated?
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What Kind of Insurance Do I Have?
It is very important to understand your type of insurance.
- Traditional indemnity insurance, sometimes referred to as "fee for service" (such as Blue Cross/Blue Shield)
This type of plan allows you to go to any doctor or hospital you select, anywhere in the United States or even abroad. Although contracts vary, you will generally be responsible for a deductible and co-payments.
- Health Maintenance Organization (HMO)
HMOs vary greatly, but they are essentially organizations that contract with large numbers of patients to achieve a volume discount on healthcare costs. You are assigned a primary care physician who manages your care and refers you to specialists within the plan when necessary. You (or your employer) pay a fixed annual premium, which is generally less costly than for an indemnity plan.
- Preferred Provider Organization (PPO)
A PPO allows you to see a doctor from the plan’s network of physicians for a small co-payment fee or to go out of the network to doctors of your choice. If you choose an out-of-network doctor, you must pay the balance between the PPO’s scheduled fee and the billed amount.
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Learn What Your Coverage Includes Before Beginning Treatment
You might be responsible for payment of fees and services if you do not follow your insurance plan’s guidelines.
- Is preauthorization required for some surgical procedures or treatments? If this is the case, ask your doctor for the CPT codes and find out if the treatment is covered. If it isn’t, you can appeal. Ask your doctor to explain why the procedure is necessary.
- Does your coverage have any exclusions—items or services for which benefits are not provided? For example, some plans that cover cancer therapy do not cover the expensive growth factors often required to replace blood cells depleted by chemotherapy.
- Are second opinions covered? Or, are they required for certain procedures such as surgery?
- If you are covered by an indemnity plan, what are the amounts of your yearly deductible and the percentage of your co-payment (usually 20%)? Cancer therapy is expensive, so you also should find out whether your plan has a maximum per calendar year out-of-pocket expenditure. In some plans, once a patient has paid $3,000 in deductibles and co-payments, the insurance plan provides full coverage of the balance.
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Payment and Billing Procedures
The doctor’s office or medical facility where you are treated may help you figure out billing procedures.
- At a hospital, clinic, or hospital-affiliated doctor’s office
If any member of your healthcare team is in practice within a hospital, the hospital billing department will usually bill your insurance company directly and then bill you for any balance due.
- At a private doctor’s or specialist’s office
Doctors, such as oncologists, who treat you in their own offices have various billing practices. Some doctors will bill your insurance company, but others require payment from you when services are rendered. If you pay the doctor, you are responsible for sending the receipt to your insurance company for reimbursement.
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Get Organized! Get All Your Paperwork Together and Keep It in One Place
You can use a three-ring binder or file folders to organize your papers. Store your "Explanation of Benefits" here, as well as bills, statements, and payment records. Then, whenever you call your insurance company, hospital billing department, or doctor’s office, you can easily refer to your records.
1. Basic information
- Personal information: date of birth, social security numbers, work phone numbers for you and your spouse or other person you designate
- Insurance information: policy numbers, addresses, phone numbers
- Physician information: names, addresses, phone and fax numbers for all your physicians, past and present
2. Reports
- All surgery and pathology reports
3. Consultations and letters
- Letters from physicians, second opinions
4. Test/Lab results
- Blood work, x-rays, bone scans, etc.
5. Calendar
- A record of appointments, schedules that track your treatment
6. Log
- A diary of events related to your treatment
7. Insurance/Financial data
- Bills, statements, explanation of benefits, payment records, etc.
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File Claims for All Covered Costs
Many cancer patients don’t take full advantage of their insurance plans. This may occur because they don’t know about a benefit, because they are confused, or because they are put off by the paperwork. If you need help filing a claim and your friends and family can’t assist, ask a social worker for help. Private companies and some community organizations also offer help with filing insurance claims.
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When Coverage Is Denied
The appeals process
At some point, some of your claims may be turned down or reimbursed at a reduced level. There are many reasons for claim rejection. However, you can appeal a refused claim or a reduced payment. Here are five ways to approach your insurance company about your claim.
Step 1—Phone your insurance company
If the reason is a clerical error, such as an incorrect code or a misstated date of service, simply file a corrected claim.
Step 2—Appeal by phone
Appeal the decision if coverage has been denied for something that is not excluded under your policy. You can sometimes request over the phone that your claim be reviewed.
Step 3—Appeal by mail
If a phone request is refused, write a letter to the insurance company stating why you think the procedure should be covered. Enclose a copy of the denial notification you received. You also might ask your doctor to explain to the company why the service meets the requirements for coverage under your policy.
Step 4—Request physician review
Ask that your claim and your case be reviewed by a physician with the same specialty as the doctor who ordered your treatment or procedure. Request a copy of the specific statement from the policy or the benefits booklet that explains why coverage is being denied or paid at a reduced level.
Step 5— Write to your state insurance commissioner
Consider sending a duplicate mailing of your appeal letter to your state insurance commissioner. Include a brief cover letter explaining your problem and ask for assistance in resolving the issue.
"Your policy does not cover this procedure"
If you receive the explanation that "your policy does not cover this procedure," you have the right to see that policy language in writing.
- Make certain that these policy restrictions were in place when you were originally covered by your contract with the plan and started paying premiums.
- If the restrictions were not initially in place, you may have the right to coverage under the insurance laws of your state.
To locate a copy of insurance laws online, go to
http://www.healthinsuranceinfo.net. This site will let you view booklets for every state and the District of Columbia on "Getting and Keeping Health Insurance." The site also provides phone numbers for each state’s insurance department.
Possible reasons for claim rejection
- Claim form not complete
- Diagnosis missing or incomplete
- Date of appointment or procedure missing or not correct
- Patient name or number missing
- Claim form illegible
- Multiple appointments on the same date
- Specialist seen without prior referral
- Charges considered unreasonable (too high) and unusual (out of the ordinary)
- Claim processor narrowly interpreted the insurance rules
- Claim processor made a mistake
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Get a Case Manager on Your Case
If you find that you’re in almost constant dispute with your insurance company, you may want to inquire about case management. Most insurance companies have case managers, often registered nurses, who act as liaisons between you and the company and help to coordinate payments to your healthcare providers.
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The Patient Advocate Foundation
If your insurance company does not have case managers or your claims are still being denied, you may want to turn to the Patient Advocate Foundation (PAF). The PAF acts as a liaison between patients, insurers, employers, and creditors. The foundation frequently deals with denied access to clinical trials or home healthcare and with restrictions on payment for prescription drugs. You can access the PAF online at
http://www.patientadvocate.org.
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If You Don't Have Insurance
It may be worthwhile to investigate other sources of financial aid if you are not covered by an insurance plan.
- When you are already in treatment
Ask your healthcare provider’s office staff to suggest some options.
- When you are not yet in treatment
You may qualify for Medicaid or Family Health Plus. The criteria for Medicaid eligibility vary among states. Family Health Plus is comprehensive insurance offered by some states at no cost to lower-income families without health insurance who are not eligible for Medicaid. The Social Services department of your local hospital will have applications for these programs.
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Help From the Federal Government
The 1996 Health Insurance Portability and Accountability Act (HIPAA) protects you when you want to switch, keep, or buy new health insurance. Also known as the Kennedy-Kassebaum Act, HIPAA:
- Limits exclusions on preexisting conditions in group health plans
- Gives new enrollees credit for prior coverage
- Makes it illegal to use health status as a reason for denying health coverage
- Guarantees group coverage for employers with 50 or fewer employees
- Guarantees renewability of group health plans
Information on the provisions of this act can be obtained online at
http://www.healthinsuranceinfo.net.
Except for people over age 65 who are covered by Medicare and people with low incomes who are covered by Medicaid or Family Health Plus, insurance in the United States is the individual’s responsibility. Most often, health insurance coverage is provided through employment, either through your own job or through your spouse’s employer. For online tips to make the most of your insurance, go to:
http://www.cancer.gov/cancerinfo/.
Sources of Information
For additional financial information to help you cope with issues arising from lung cancer, you may wish to contact these organizations:
- Health Insurance Association of American (HIAA)
1201 F Street, NW, Suite 500
Washington, DC 20004-1204
1-202-824-1600
http://www.ahip.org/content/default.aspx?bc=41
Provides insurance guides for consumers on topics such as health insurance, managed care, disability income, long-term care, and medical savings accounts.
- Social Security Administration (SSA)
http://www.ssa.gov
Provides comprehensive information about two programs, Social Security Disability Insurance and Supplemental Security Income.
- Pharmaceutical Research and Manufacturers of America (PhRMA)
1100 15th Street, NW
Washington, DC 20005
1-202-835-3400
http://www.phrma.org
A Web site offering information about pharmaceutical manufacturers' drug assistance programs for those in financial need.
- Patient Advocate Foundation (PAF)
700 Thimble Shoals Blvd., Suite 200
Newport News, VA 23606
1-800-532-5274
http://www.patientadvocate.org
PAF provides education and legal counseling for cancer patients concerning insurance and financial issues.
Additional Resources
Knowing where to find credible and accurate information is an important step in getting the most benefit from your health insurance. The following resources may help:
The Activist Cancer Patient: How to Take Charge of Your Treatment
Beverly Zakarian
John Wiley & Sons
ISBN: 047-112026X, 240 pages
May 1996
What Cancer Survivors Need to Know About Health Insurance and
Working It Out—Your Employment Rights As a Cancer Survivor
National Coalition for Cancer Survivorship (NCCS)
1010 Wayne Avenue, Suite 770
Silver Spring, MD 20910
1-877-NCCS-YES (622-7937) [General information and publication orders]
1-301-650-9127
http://www.canceradvocacy.org
What the Health Insurance Reform Law Means for Women & Families, and
Guide to the Family & Medical Leave Act
National Partnership for Women & Families
1875 Connecticut Avenue, NW, Suite 650
Washington, DC 20009
1-202-986-2600
http://www.nationalpartnership.org
Both available free of charge.
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