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Maximizing Your Insurance Coverage

by Susan H. Loeb, JD

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Part of successfully coping with cancer includes having control over your medical bills and insurance. It’s not easy for anyone, let alone someone undergoing cancer treatment. To maximize your health benefits, you need to know how to navigate the system, safeguard your existing coverage, and understand what is available if you have insufficient coverage or no coverage at all.

Understanding Your Coverage
If your insurance plan is a preferred provider organization, or PPO, you should know your deductible, co-insurance, co-payments, and annual out-of-pocket limit. Use in-network providers, if possible, to avoid large bills. Be sure to ask your specialist if he or she is part of the PPO network because out-of-network doctors often work within in-network treatment centers. If you go to an out-of-network provider, you are responsible for paying the amount over the PPO approved amount. This amount will not count towards your out-of-pocket limit.

With health maintenance organization, or HMO, coverage, your primary care doctor controls your access to specialists. Make sure that you obtain a referral before treatment starts because without the referral, the HMO won’t pay. If you wish to receive treatment from non-HMO doctors, you will have to demonstrate that the outof- network treatment is superior to and not available through the HMO. You will need to get your primary care physician and managed care doctors to support you in this request.

Understanding the Insurance Process
When you receive medical services, the provider submits a claim to the insurer with industry-standard billing codes for treatment and diagnoses. The codes drive the entire determination of coverage and benefits. When the claim is processed, an Explanation of Benefits is generated, listing the provider, the date of service, the total charge, the approved amount, the amount paid, and the amount you may be billed. Keep EOBs in chronological order by date of service. When you receive a bill, compare it against the EOB, and don’t pay it until you are satisfied that it is correct. Never pay a provider until you have seen an EOB.

You need to know how to navigate the system.

Author of Article photo

Susan H. Loeb

Claim Problems and Denials
Insurers can incorrectly pay for or flatly deny coverage for a variety of reasons. Claim denials due to clerical coding errors are very common and are the easiest to fix if you are willing to spend the time needed to correct them. Contact the insurer if you suspect that your claim was denied because of an incorrect diagnosis or service code. Ask for the reason for the denial, and request the procedure code(s) and/or diagnosis used. If the provider erred, ask them to resubmit the claim with the correct information. Insurers will not reprocess such errors on their own.

If an insurer determines that a service is not “medically necessary,” it will deny the claim, especially in the precertification process. To get coverage, your doctor will need to submit additional medical information to show “medical necessity.” If the insurer still refuses to pre-certify, follow the formal appeal process set forth in your plan or policy.

The scariest denial is when the insurer determines that the service is not covered by your plan or policy. A common exclusion invoked in cancer treatment is services deemed as “experimental treatment.” To overturn such a denial, you must follow the appeals process and procedures. You cannot circumvent this time-consuming and sometimes lengthy process. But if you stick with it, you may very well prevail. In preparing an appeal, follow these steps:

  • Ask doctors to join in the appeal.
  • Notify your provider that you are appealing so your claim is not placed in collection.
  • Ask questions until you understand fully the factual basis for the denial.
  • Take copious notes, including the name of the person you spoke with, the date, and the time. Careful notes can prove invaluable.
  • Remain cordial; be professional.
  • Keep the appeal concise and directed, but complete. If you ultimately resort to litigation, the court’s role may be limited to whether the denial was arbitrary and capricious.
  • Enlist the support of your employer, if appropriate.
  • Don’t give up. Insurers don’t make it easy, but many denials are overturned.

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Susan Loeb is an attorney and founder of Your Benefits Advocate. YBA provides advocacy, consulting, and administrative services to individuals seeking help in solving problems with their health and disability benefits.

Navigating the system on your own can be overwhelmingly difficult. For help, contact your state's Department of Insurance, support organization such as the Patient Advocate Foundation, the Alliance of Claims Assistance Professionals, or a private attorney.

This article was published in Coping® with Cancer magazine, November/December 2007.