Kristie L. Kahl: After receiving a diagnosis, why is it important for patients to understand their benefits? What should they look for in particular?
Monica Fawzy Bryant, Esq: At Triage Cancer, we think there should be a class in high school on understanding health insurance and finances, because everyone has to understand it. But we’re never actually taught what the different words mean, or really how to understand the various benefits. So, first and foremost, what people need to understand is the network of providers that are included in their health insurance policy, because their coverage is really going to differ depending on if they’re seeing in-network providers.
The other major piece that people need to understand is their out-of-pocket maximum. So, most health insurance policies have a cap on the amount that they’re going to have to pay out of pocket. And the way you get to that cap is by generally adding up everything you’re paying towards your deductible, towards your co-payments and towards your coinsurance. And once you’ve met that out-of-pocket maximum, the insurance company is supposed to pick up 100% of costs moving forward.
Kahl: What are some tips for patients who have to appeal any insurance denials?
Bryant: The one thing I’d love everyone to walk away with is the idea that they don’t have to take no for an answer. So if someone receives a denial from their health insurance company, the very first thing they should do is understand how to appeal that denial. Again, depending on the type of insurance, the specifics may differ, but generally speaking, there’s going to be at least two levels of appeals.
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 does not get the approval at the internal phase, then they have the right to do what’s called an external appeal. And that’s where you go to an independent entity in your state. And that independent entity looks at all the evidence, looks at the plan, looks at the medical circumstances and decides if that service or prescription drug is medically necessary. And whatever that independent entity decides is binding.
I will tell you that, of the 200 million claims that are denied each day … we know that generally 99.9% of denied claims are never appealed. We also know that when people do appeal, about 50% of the time the decision is in favor of the patient. So it’s hard, because appealing is this extra thing that we’re asking people to do while they’re also coping with their cancer diagnosis and the rest of life; however, it is almost always in their best interest to at least try to appeal because the insurance company may have gotten it wrong.
Kahl: How can patients negotiate for and advocate for themselves with insurance?
Bryant: It’s tricky. Asking a lot of questions is really important. It can be hard, from the patient and caregiver perspective, to understand what is their responsibility? What are the pieces (of insurance) that the doctor or the hospital is going to do? It can take a lot of perseverance with the insurance companies sometimes. It’s going to take multiple phone calls. So I think certainly asking all a lot of questions. And if you don’t get the answer that you need, keep asking.
The other piece and it is to stay organized. So there’s potentially going to be explanation of benefits (EOB) and bills, and tons of paperwork coming from the provider side, from the insurance company. If someone has to go through an appeal, there’s going to be more paperwork. And so being really organized is going to be important in the process. That could be a filing cabinet, that could be a three-ring binder, electronic files, it doesn’t matter as long as people are keeping track of what they’ve paid, what EOB they’ve gotten, where they are in the appeals process, because it can get a little bit overwhelming to do all of this.
The last piece, in terms of advocating for themselves, is particularly around the appeals process. People should know that at the end of the day, it is their responsibility to ask for prior authorizations, and to appeal those denials. There are many health care teams out there that are really great, and will do that on behalf of their patients. At the end of the day, it is in fact the patient’s responsibility.
Kahl: Do you have any financial assistance programs our patients can look into?
Bryant: At Triage Cancer, we provide free education on all the legal and practical issues that can arise after 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 impact what you have access to. So if someone goes to our resources page and goes to health insurance, for example, they will see all of our health insurance appeals information. We have videos, quick guides, checklists and tracking forms. And all of that can be downloaded on our website. We also have a number of educational events where someone can come learn live, so you can join from the comfort of your own home and the dates and registration are all available on triagecancer.org.
Transcription edited for clarity and conciseness.
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