Ways to Cover the Cost of Cancer within the Constraints of Insurance Networks

At times your path to overcoming cancer requires you to stray from the path your insurance provide may have in place. The doctor you need is not in the insurance providers “network”, a new medical treatment such as proton therapy may not be covered yet, the particular hospital that specializes in your form of the disease is not on the insurers list. You need to focus on obtaining the best forms of treatment to help you fight the disease.

Fortunately, today more and more hospitals, doctors, clinicians are willing to work with you and your insurer to find a way to get the treatment needed covered. But it takes effort on your part to make it happen.

If your doctor tells you that you have cancer, find out right away whether you’re covered for the additional tests and treatments you need. “Cancer treatment is expensive, and there is no shame in discussing your concerns about the cost and figuring out ways to lower it,” says Shelley Fuld Nasso, CEO of the National Coalition for Cancer Survivorship. Now more insurers, hospitals and oncology practices are helping patients navigate the insurance system, cover out-of-pocket expenses and find additional resources.

At the many clinics and hospitals, a financial counselor gets involved right away. “Right away, we do a huddle,” says Kimberly Bell, administrator for cancer services at the Cleveland Clinic. “We help patients get insurance authorization and understand their out-of-pocket costs and co-pays.”

Some health insurers will assign you to a case manager. Cigna, for example, has hired oncology case managers who are registered nurses to help cancer patients understand their coverage. United Healthcare has similar case managers, as well as a program for those with breast cancer.

Your insurer’s case manager can help you find specialists who are in-network. That specialist may belong to a local oncology practice, but for complex cases, your insurer may cover treatment by oncologists and other doctors at a major cancer center that isn’t necessarily nearby.

Cigna, for example, can make a “network adequacy exception” if you cannot find the right specialist in its network, says Dr. Ajani Nimmagadda, senior medical director at Cigna. Work with the doctor or hospital to make the case for why you need to use a particular specialist. “We need to understand the clinical information and how this out-of-network physician is able to do what the in-network physician cannot,” says Nimmagadda.

If the insurer refuses to cover an out-of-network provider, ask the doctor or hospital if there’s anything else they can do. “Call the financial office and say, ‘I want to stay with you. Can you work with me to negotiate a lower rate?’”, says Kirsten Sloan, vice president for policy for the American Cancer Society’s Cancer Action Network.

If you’ve received a diagnosis close to open-enrollment season (in the fall for most plans), you may be able to switch to another plan that includes the specialist in its network.

The most common reason insurers don’t approve a treatment plan is because “we don’t have all of the information,” says Cigna’s Nimmagadda. Your oncologist or hospital can help provide documentation for the appeal. “We send in the journals and articles,” says Bell, of the Cleveland Clinic. “We’re working directly with the payers and talking to them about different authorization processes or rationales for denial.”

You can also hire a medical claims specialist to help gather evidence and file an appeal. Most charge $75 to $95 per hour (to find one, visit www.claims.org).