• Have you had to fight your insurance company to get them to pay for something?

    Asked by GregP_WN on Saturday, May 18, 2019

    Have you had to fight your insurance company to get them to pay for something?

    Judge rips insurance company for 'immoral, barbaric' cancer denials

    Read this article about insurance companies denying claims for some of the newer and better types of treatments.
    https://cnn.it/2HDZFz3

    11 Answers from the Community

    11 answers
    • carm's Avatar
      carm

      Greg, you know I read this article and I do indeed work for that insurance company. Currently in the US, there are maybe 30-35 Proton Beam treatment centers. So many patients have to go out of state and out of network to get this therapy. The NCCN guidelines are very specific on the indications for its use. I recently had a patient with tonsil cancer whose doctor ordered proton beam instead of the indicated IMRT therapy. IMRT is indicated for the left side of the chest, any organ in the pelvic cavity and anything above and including the tonsils. So in order to get Proton beam, a physician has to explain his rationale, give specifics like number of doses, strength of dose and an estimate of surrounding organs or tissue that will be effected surrounding the main tumor...a percentage. The patient did get the proton beam after the MD did the peer to peer (PTP) with the Medical Director. It was denied first, denied on appeal because the info requested not given and then finally approved in the PTP. Insurance companies like physicians have to adhere to the NCCN guidelines. Those guidelines are the consensus of many from some of the best hospitals like Mayo, Memorial Sloan, MD Anderson, etc. That's who set the guidelines. I understand why that article was written and the anger behind it. However, we are held to the same standards as physicians. If a doctor is going to order something not approved for a specific indication, then they need to come with all the data that justifies going outside the guidelines and off label. I'm sure I'll be alone here but working with some of the big insurers it is the process we all have to follow. I sympathize with patients who have trouble getting PET scans or proton beam. However, their MD knows they will be denied when they place the order, and many refuse to send the additional info for approval.

      4 months ago
    • Russ' Avatar
      Russ

      Hello Greg, You know I have had major surgery twice now during the past 20 years. In that time I have never spoken to my insurance agents. I have Medicare as my primary and we each have a medigap policy for which we pay dearly.

      4 months ago
    • PaulineJ's Avatar
      PaulineJ

      All the time.How did you know?

      4 months ago
    • GregP_WN's Avatar
      GregP_WN

      Thanks Carm, I do know that new treatment types are denied very often for one reason or another. Thanks for sharing that about this company and how it works.

      4 months ago
    • BarbarainBham's Avatar
      BarbarainBham

      I've never had anything denied. I don't know whether I should thank my Blue Cross Blue Shield of Alabama insurance or the efficiency of the doctors at the medical center where I go (Univ. of Alabama at Birmingham, which is one of the NCI--designated CCC's).

      4 months ago
    • cllinda's Avatar
      cllinda

      I never had anything denied. And with my son's accident, they were constantly making sure that he was getting all the help he needed for a full recovery. I was very pleased with Blue Cross Blue shield.

      4 months ago
    • lo15's Avatar
      lo15

      Yup, they didn't want to pay for Nuelasta and tried any way they could to not pay. I refused to sit back and called and called and complained. Finally they started paying for me to administer the shot but it took forever. The sad part was how many different explanations you get from one company and the lack of knowledge on their parts. Worst part was that we could always go have it administered at a hospital for more money than it would have cost for me to do at home. Get sick, you will learn a lot about insurance

      4 months ago
    • BuckeyeShelby's Avatar
      BuckeyeShelby

      Thanks, Carm. As an employee of a medical TPA, I understand it. In addition to limitations based on standard of care, in some instances employers also have restrictions placed, for instance specific types of surgeries might have to be done in a Center of Excellence.

      Lo15 -- I'm not talking about when we get to the detailed reviews of stuff, but the people you are speaking with on the phone -- yeah, if you are lucky they have a college degree. I know because I audit customer service phone calls. You can't get detailed info from these reps. They are not medical personnel. If you are fortunate, they've been in med insurance for a really long time. Personally, I have a degree in English & a teaching certificate. But I spent 6 years in supplementary insurance and 6 years in workers comp. Plus the 7 years I've been w/the med TPA. So... The reps are making more than minimum wage, but they are not pulling in $60K a year, either.

      4 months ago
    • BarbarainBham's Avatar
      BarbarainBham

      lo15, could the insurance preference for you to have your shot at your doctor's office have something to do with people selling their medicine or giving it to someone not insured by them? Or if you were giving the shot to a family member, maybe they were afraid there would be a reaction that they'd be liable for financially. I don't know, but we do have a lot of fraud in this world, plus non-clinical people not informed enough to bend their "rules." Best wishes.

      4 months ago
    • lo15's Avatar
      lo15

      Hi,
      Its common practice ( at least at Dana Farber) to be taught to do the pump disconnect and administer the Neulasta shot at home so you don't have to make the trip back to the hospital. CVS Caremark had very arbitrary rules that seemed to change daily. You would get one supply and be denied the next or it had to be approved again and we would incur long waits, forcing him to go to the hospital where it would be covered. Now he is on a different regime without Neulasta which is a good thing because there is no medicare supplement that will cover a Tier 5 drug without a huge deductible and expense. Its eye opening, oh and we had top coverage Blue/Cross which was company paid and was the best plan offered.

      4 months ago
    • PennyS's Avatar
      PennyS

      I don't have insurance, I'm on a plan offered at the hospital ( because it's a teaching hospital ). They are supposed to cover my expenses after the co-pays. Somehow they sent both my boipsies to an outside lab. I have been trying to get these bills paid since October of last year. It doesn't seem to be a big deal to them, but for me it is....not only is it a lot of money, but they are destroying my credit.

      4 months ago

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