Cancer Insurance Issues

[Alli]

Every year since I finished cancer treatments, my radiation oncologist has ordered a PETscan. This year, out of the blue, the insurance company denied it. So the doctor decided he could make do with a thigh to neck CATscan with dye. Insurance denied that, too. What pencil pusher knows better than a physician what tests are medically necessary and why have insurance companies become so powerful?

Yes, the PET is expensive. But still only a fraction of what it will cost them if the disease returns.

 

[Herdfan]

Is there any appeal process you can use like through the state insurance commissioner?

 

[Scepticalscribe]

Every year since I finished cancer treatments, my radiation oncologist has ordered a PETscan. This year, out of the blue, the insurance company denied it. So the doctor decided he could make do with a thigh to neck CATscan with dye. Insurance denied that, too. What pencil pusher knows better than a physician what tests are medically necessary and why have insurance companies become so powerful?

Yes, the PET is expensive. But still only a fraction of what it will cost them if the disease returns.

That is awful.

Is there any way you can challenge this?

 

[User.45]

Every year since I finished cancer treatments, my radiation oncologist has ordered a PETscan. This year, out of the blue, the insurance company denied it. So the doctor decided he could make do with a thigh to neck CATscan with dye. Insurance denied that, too. What pencil pusher knows better than a physician what tests are medically necessary and why have insurance companies become so powerful?

Yes, the PET is expensive. But still only a fraction of what it will cost them if the disease returns.

It's a clerical error somewhere in the system. Anytime I scream* CANCER on the phone in a "peer-to-peer" call, I get an immediate approval.
Your physician should appeal.


*I used to do the phone appeals during commute, and once my call disconnected and I started throwing F-bombs about the whole thing, then I realized it was just the BT and the call is still on. Resumed the conversation without apology.

 

[Ulenspiegel]

I am sorry to hear that Alli.

When I was receiving treatment I had to have a PETscan every three months.

But the Central-Eastern-European health insurance system differs.

I wish you luck and good health, Alli.

 

[User.45]

I am sorry to hear that Alli.

When I was receiving treatment I had to have a PETscan every three months.

But the Central-Eastern-European health insurance system differs.

I wish you luck and good health, Alli.

Don't even get me started....

 

[ronntaylor]

So sorry to read this. It's always frustrating to deal with nonsense on top of maintaining good health. My twin had a similar issue. His wife got involved and her 25+ years as a teacher helped him get the treatment decided by his docs. As others suggested, get your doctor involved to have his orders followed.

 

[Alli]

Is there any appeal process you can use like through the state insurance commissioner?

Is there any way you can challenge this?

Not a clue. This kind of thing has always been handled by the doctors. I stay out of it because I don’t know any more than the pencil pusher who denied it in the first place. Right now I’m waiting to hear from the radiation oncologist. I suspect if he doesn’t get anything he’ll call in the medical oncologist and they’ll double team the insurance company.

 

[Scepticalscribe]

Not a clue. This kind of thing has always been handled by the doctors. I stay out of it because I don’t know any more than the pencil pusher who denied it in the first place. Right now I’m waiting to hear from the radiation oncologist. I suspect if he doesn’t get anything he’ll call in the medical oncologist and they’ll double team the insurance company.

The very best of luck with it.

 

[AG_PhamD]

Every year since I finished cancer treatments, my radiation oncologist has ordered a PETscan. This year, out of the blue, the insurance company denied it. So the doctor decided he could make do with a thigh to neck CATscan with dye. Insurance denied that, too. What pencil pusher knows better than a physician what tests are medically necessary and why have insurance companies become so powerful?

Yes, the PET is expensive. But still only a fraction of what it will cost them if the disease returns.

There is an appeals process for claim denials. I imagine your doctor will work on this. I would expect this will be resolved successfully with the insurer. Just in case, make sure you document all communications with them and have copies of any related paperwork. If they continue to deny the claim there are ways to escalate your appeal using consumer protection agencies.

Fear not, if I can get insurers to pay for medications that cost thousands that’s not on their formulary, I’m optimistic your doctors can get you a PET or CAT scan. It just might take some time and effort.

This denial business is absurd, I know. Between the amount of denials and prior-authorizations insurance has, it’s amazing any treatment can happen. And it gets worse and worse every year.

Denials seem to happen for the sake of denials. In the pharmaceutical world you can follow the insurer’s requirements and prerequisites to a T and they will deny the claim. It’s not only until you call them out on it that they then agree to pay. I think their hope is that a different treatment is chosen.

On a similar note, Biden is requiring insurance to pay for at-home rapid COVID tests. While it’s great that COVID tests will be free and these tests should be covered, it’s ridiculous people will have to manually submit for reimbursement. Do you know how many times I’ve submitted claims and they are arbitrarily denied or ignored altogether? There are much more efficient ways of doing this. I suspect the difficulty is built in by design at the behest of the insurers.

 

[shadow puppet]

@Alli, last year when Anthem Blue Cross denied me getting a life saving Mitra clip procedure since I'm too high risk for open heart surgery, we appealed. Three times. Then a Blue Cross rep said I have the right to appeal to the state, so I did and won. The state overrode Blue Cross and I was able to have the procedure covered by Blue Cross.

Please check into this possibility in your state. It certainly can't help to try and it could make all the difference for you.

Please also keep us posted.

 

[SuperMatt]

As discussed in other threads, issues with insurance you personally pay for are just as bad, if not worse, than any Medicare or Medicaid issues. It still baffles me that SOME people, faced with these insurance issues, would rather keep paying through the nose for it instead of embracing universal healthcare.

Decades of “the government is bad at everything” propaganda have really seeped into people’s minds to the point where they cannot even see their hand in front of their face.

 

[Alli]

As discussed in other threads, issues with insurance you personally pay for are just as bad, if not worse, than any Medicare or Medicaid issues. It still baffles me that SOME people, faced with these insurance issues, would rather keep paying through the nose for it instead of embracing universal healthcare.

Decades of “the government is bad at everything” propaganda have really seeped into people’s minds to the point where they cannot even see their hand in front of their face.

I’m paying for my insurance. That does make it annoying to say the least. I used universal healthcare for the first 21 years of my life (Aim High, Go Air Force). It worked. I believe in it.

 

[User.45]

@Alli, last year when Anthem Blue Cross denied me getting a life saving Mitra clip procedure since I am too high risk for open heart surgery, we appealed.

Insane... Like they were the ones taking the actual risk. The prior authorization system is designed to waste provider time and in no other field would it be acceptable to dollars worth of physician time, to save a few hundred bucks on something that is only 3x more expensive in the USA because of administrative fees...

Results: U.S. insurers and providers spent $812 billion on administration, amounting to $2497 per capita (34.2% of national health expenditures) versus $551 per capita (17.0%) in Canada: $844 versus $146 on insurers' overhead; $933 versus $196 for hospital administration; $255 versus $123 for nursing home, home care, and hospice administration; and $465 versus $87 for physicians' insurance-related costs. Of the 3.2-percentage point increase in administration's share of U.S. health expenditures since 1999, 2.4 percentage points was due to growth in private insurers' overhead, mostly because of high overhead in their Medicare and Medicaid managed-care plans.

Limitations: Estimates exclude dentists, pharmacies, and some other providers; accounting categories for the 2 countries differ somewhat; and methodological changes probably resulted in an underestimate of administrative cost growth since 1999.

Conclusion: The gap in health administrative spending between the United States and Canada is large and widening, and it apparently reflects the inefficiencies of the U.S. private insurance-based, multipayer system. The prices that U.S. medical providers charge incorporate a hidden surcharge to cover their costly administrative burden.

Health Care Administrative Costs in the United States and Canada, 2017 - PubMed

None.

pubmed.ncbi.nlm.nih.gov

Meanwhile our outcomes on basic stuff like maternal and neonatal mortality are less than mediocre.

 

[SuperMatt]

I’m paying for my insurance. That does make it annoying to say the least. I used universal healthcare for the first 21 years of my life (Aim High, Go Air Force). It worked. I believe in it.

As a fellow military member, the full health coverage is a huge benefit. But wouldn’t it be nice if we could pick jobs based on something other than the health plan? I fully support universal health care.

 

[User.45]

As a fellow military member, the full health coverage is a huge benefit. But wouldn’t it be nice if we could pick jobs based on something other than the health plan? I fully support universal health care.

Is it lifelong TriCare?

 

[SuperMatt]

Is it lifelong TriCare?

I haven’t retired yet, but there are multiple Tricare options once I get to that point.

 

[User.45]

I haven’t retired yet, but there are multiple Tricare options once I get to that point.

I'm a hardcore pacifist (as many may have noticed here), but I really love military patients. One of the funniest things is when they complain about TriCare. Pre COVID, we saw this young guy for a consultation and couldn't load his imaging to the system. Turned out the military encrypted it. I found this equally amusing and infuriating.

 

[AG_PhamD]

Every year since I finished cancer treatments, my radiation oncologist has ordered a PETscan. This year, out of the blue, the insurance company denied it. So the doctor decided he could make do with a thigh to neck CATscan with dye. Insurance denied that, too. What pencil pusher knows better than a physician what tests are medically necessary and why have insurance companies become so powerful?

Yes, the PET is expensive. But still only a fraction of what it will cost them if the disease returns.

Curious if you were able to sort this out.

 

[Alli]

Curious if you were able to sort this out.

Waiting until I see the medical oncologist in August.