Transcription:
Kristie L.Kahl: After receiving a diagnosis, why is it important for patients to understand its benefits? What should they look for in particular?
Monica Fawzy Bryant, Esq: At Triage Cancer, we think there should be a high school lesson in understanding health insurance and finances, because everyone needs to understand this. But we\’re never actually taught what the different words mean, or really how to understand the various benefits. So first of all what people need to understand is the network of providers that are included in their health insurance policy, because their coverage is going to really differ depending on whether they see providers in the network.
The other important piece that people need to understand is their own pocket maximum. Hence, most health insurance policies have a limit on the amount they will have to pay out-of-pocket. And the way you get to that limit is generally by adding up everything you\’re paying for your deductible, your co-payments, and your coinsurance. And once that out-of-pocket maximum is reached, the insurance company would have to collect 100% of the costs going forward.
Kahl: What are some tips for patients having to appeal insurance denials?
Bryant: The one thing I\’d like everyone to walk away with is the idea that they don\’t have to take no for an answer. So if someone gets a disclaimer from their health insurance company, the first thing they should do is figure out how to appeal that disclaimer. Again, depending on the type of insurance, the specifics may differ, but generally there will be at least two levels of appeal.
The first is an internal appeal. And that\’s where you go back to the insurance company and ask them to reconsider. So maybe it\’s about adding more information or providing additional documentation or evidence. But even if someone doesn\’t get approval in the internal stage, then he has the right to make what is called an external appeal. And that\’s where you go to an independent entity in your state. And that independent entity reviews all the evidence, reviews the plan, reviews the medical circumstances, and decides whether that service or prescription drug is medically necessary. And whatever that independent entity decides is binding.
I\’ll tell you, out of the 200 million denied claims every day, we know that generally 99.9% of denied claims never get appealed. We also know that when people appeal, about 50% of the time the decision is in favor of the patient. So it\’s hard, because appealing is this one more thing that we ask people to do while also coping with their cancer diagnosis and the rest of their lives; however, it is almost always in their best interest to at least try to appeal because the insurance company may have been wrong.
Kahl: How can patients negotiate and defend themselves with insurance?
Bryant: It\’s complicated. Asking lots of questions is really important. Can it be difficult, from the perspective of the patient and the caregiver, to understand what their responsibility is? What pieces (of insurance) will the doctor or hospital do? Sometimes it can take a lot of persistence with insurance companies. It will take more phone calls. So I think certainly ask everyone a lot of questions. And if you don\’t get the answer you need, keep asking.
The other piece and you stay organized. So potentially there\’s going to be an explanation of benefits (EOB) and bills, and tons of paperwork coming from the provider side, from the insurance company. If someone has to file an appeal, there will be more paperwork. And so being really organized is going to be important in the process. It could be a filing cabinet, it could be a three ring binder, electronic files, it doesn\’t matter as long as people keep track of what they paid, what EOB they got, where they are in the appeals process, because it can get a little overwhelming do all of this.
The last bit, in terms of defending yourself, is specifically about the appeals process. People should know that it is ultimately their responsibility to seek prior permissions and to appeal those denials. There are a lot of healthcare teams out there that are really amazing and will do this on behalf of their patients. At the end of the day, it is indeed the patient\’s responsibility.
Kahl: Do you have financial assistance programs that our patients can look into?
Bryant: At Triage Cancer, we provide free education on all legal and practical matters that may arise following a diagnosis, including health insurance, employment and finances. On our website, we have our resources broken down by topic and by location, because sometimes where you live can affect what you have access to. So if someone goes to our resource page and addresses health insurance, for example, they\’ll see all the information about health insurance appeals. We have videos, quick guides, checklists and tracking forms. And all this can be downloaded on our website. We also have a series of educational events where someone can come learn live, so you can join from the comfort of your home and the dates and registration are all available at triagecancer.org.
Transcription edited for clarity and conciseness.
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