The rules of our health care system are not always clear. And sometimes they are unfair. For example, it isn't always clear what care is covered by a health plan or why. And the rules about coverage and other health care decisions vary a lot from health plan to health plan.
NBCC believes the health care industry needs much better rules about breast cancer care. These rules must be given to everyone in an easy-to-understand way. And when the rules are broken, patients need a quick and easy way to get the problem fixed.
For now, patients who want to challenge their health plans' decisions usually must begin with an appeal. The health plan itself designs its own appeals process. So it may be a long and frustrating process. But sometimes the fight is well worth it.
What You Can Do:
You may face a number of problems with our health care system. Your health plan may limit your choice of doctors or care centers. Or maybe your health plan won't pay for care that you need. Or maybe one of your caregivers has given you the wrong care.
Sometimes it's hard to get to the root of the problem. For example, let's say your doctor recommends a treatment that your health plan won't cover. Is the problem that your health plan won't pay for a treatment that you need? Or is the problem that your doctor is recommending a treatment that isn't effective? Either is possible in our health care system. That's why it is important to understand the evidence behind your doctor's treatment recommendations.
You need to know the source of the problem. That way you can decide whether you want to appeal your health plan's decision.
What is the goal of an appeal? The goal is to get your health plan to change their decision and pay for care that will help you.
Remember -- more care does not always mean better care.22
Every health plan is different. So be sure you understand what services your plan does and does not cover. Health plans can limit your choice of doctors and care centers. They can also limit the type of care they cover.
Keep in mind that employers buy most private health insurance. Employers can decide how much coverage to offer their employees. They can base this on how much they want to spend. That means that sometimes even a proven treatment isn't covered by your health plan. For example, employers can decide not to cover mental health services even though they can be "needed and effective."
Also, Medicare does not cover prescription drugs used outside the hospital. However, Medicare does now cover five oral breast cancer drugs through the Medicare Prescription Drug Program including tamoxifen, and several aromatase inhibitors.23
Health plans have to be honest about what they do and don't cover--and why. They have to cover the same things for everyone on the same plan. But they don't have to cover everything.
Read your policy and your denial letter to find out about the appeals process. Find out who to talk to about the denial. (This information may be in your denial letter. Or you may have to call your health plan.) Then you should:
Request copies of your medical records. Under the HIPAA privacy rules, health plans, doctors, hospitals, clinics, nursing homes, and other direct-care providers should provide access to your records within 30 days. Also try to get copies of any correspondence between your doctor and your health insurance carrier, including your doctor's "request for payment authorization." Although the HIPAA privacy rules give you the right to access your medical records, your doctor or health plan may charge you a fee for copying and sending them.
Learn all you can about your illness, what your doctor advises for your treatment, and why. Ask your doctor if there is evidence from medical studies that this treatment will help you. This information will help you make the best appeal you can.
Your appeal letter should tell your health plan why you think the plan should pay for your care. The letter should be clear, firm, and polite. You should tell them:
Get a signed statement from your doctor that specifically describes your illness and what is needed to treat it. (Were there any specialists called in to consult or treat you? Get them to sign statements, too.) This statement should also include a short medical history and your prognosis with and without treatment. Your doctor(s) should include copies of peer-reviewed research articles relevant to your illness and proposed treatment. If possible, send all of this information to your insurance carrier with your first written appeal.
The information in this guide can't take the place of legal advice. A lawyer can file your case in court if that is the only option you have left. He or she can also tell you if what your health plan or caregiver did was against the law. Would you like help from a lawyer, but you can't afford to pay for one? There are lawyers who may be able to give you free advice. Contact the American Bar Association for their Consumers' Guide to Legal Help to locate free legal resources in your area.
You may have to be stubborn and demanding when you make your appeal. Your health may make it hard for you to fight for your own treatment. A friend or family member may be able to help you make your appeal.
22. Stadtmauer EA, O'Neill A, Goldstein LJ, et al. Conventional-dose chemotherapy compared with high-dose chemotherapy plus autologous hematopoietic stem-cell transplantation for metastatic breast cancer. Philadelphia Bone Marrow Transplant Group. N Engl J Med 2000 Apr 13; 342(15): 1069-76.
Peters WP, Rosner G, Vredenburgh J, et al. Updated results of a prospective, randomized comparison of two doses of combination alkyating agents (AA) as consolidation after CAF in high-risk primary breast cancer involving ten or more axillary lymph nodes (LN): CALGB 9082/SWOG 9114/NCIC MA-13. Proc Am Soc Clin Oncol 2001; 20: A-81, 21a.
23. See NBCCF for more information about breast cancer drug coverage and eligibility through the Medicare Prescription Drug Program.