[ Inglés] Navigating Health Insurance: What Can Patients Do If They’re Denied Access to Treatment?

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Topics include: Understanding and Financial and Insurance

What can those living with chronic lymphocytic leukemia (CLL) do if a claim is denied? When do people need to get an attorney involved? During this highlight from our “Access to Better Care: Overcoming Financial and Insurance Barriers” program, expert Stacey Worthy, from Aimed Alliance, and CLL patient Eliot Finkelstein share steps for others to take if they’re denied access to important testing or treatment and ways to advocate for care. Watch now to learn more.

Sponsored by Janssen Oncology and Pharmacyclics LLC.

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Transcript

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Andrew Schorr:

So, this navigation that we have to do in trying to get the medicine that we want—now, Eliot, I’m gonna skip back to your doctor. Your doctor was also making calls for you to help in your journey with CLL, right? 

Eliot Finkelstein:        

Correct. He was calling the insurance company, I presume directly. Also, my skin doctor was calling the insurance company directly, and so, relatively speaking, on the drug part and the infusions, I really didn’t have any trouble.

I will say—and, this may be too rare for most people, but I’m getting IVIg permanently for the rest of my life – infusions. And, one doctor—one of my cancer doctors—submitted my request for IVIg under my cancer. Well, it didn’t work; they denied it because it’s different requirements under cancer or CLL than it is for my skin disorder. And so, it was accepted under my skin disorder, but not under my cancer, so I almost had to yell at them to explain, and I had to tell them four times and several doctor’s offices to make sure it’s submitted under my skin disorder.

Stacey Worthy:           

That’s a really good point. I would like to piggyback on that.

A lot of times, when you’re denied access to a treatment, it could be as simple as the practitioner just using the wrong billing or coding information when submitting the claim. So, even before you do any appeals process, it’s always helpful to talk to your doctor and make sure that they are using that correct billing and coding information.

Andrew Schorr:          

When I get IVIg now, I get it at the clinic as an infusion, and I think the cost is probably $10,000. It’s a lot. Fortunately, right now, Medicare and my Medicare supplement are getting it. Some of you—I was talking to Dr. Rick Furman, who’s a CLL specialist in New York, maybe you’re his patient—some people have been saying, “Well, I get IVIg at home,” which can be administered.

I asked my doctor’s clinic about it, and they had a company call me, and apparently, under Medicare, CLL—and, maybe I’m wrong, I’m checking into this, navigating this—it’s not one of the conditions where they typically authorize IVIg at home even though it’s cheaper for them. Go figure, right?

Eliot Finkelstein:        

Yeah, really.

Andrew Schorr:          

So, you have to be an advocate. Like Eliot, you probably have to make a lot of calls. Stacey, this is so unnerving for us who are dealing with cancer.

Stacey Worthy:           

Absolutely.

Eliot Finkelstein:        

Can I add?

Andrew Schorr:          

Yeah, go ahead. We’re gonna have to fight Medicare, call our congressman, make sure our doctor has the right code…

Eliot Finkelstein:        

…let me add a couple things. One is we don’t pay a bill now until we see both the doctor bill as well as the explanation of benefits, and then we make sure everything is correct on it. That’s one. The other one is that—I just lost my train of thought. We cover ourselves, and we make sure everything matches up in what it should be.

Andrew Schorr:          

So then, it brings us to the question—Stacey, you’re a healthcare attorney. When do people need to get an attorney involved? You talked about the appeal process, which can have a couple levels, or Eliot calls an ombudsman, which is great if somebody at his insurance company can go to that.

Social media you mentioned, and our daughter Ruthie actually used that with Blue Shield of California. She rattled cages on social media. Suddenly, somebody higher up saw it and got involved. I did some peer-to-peer review that got something covered that they were saying they wouldn’t. But, when do we need to look for an attorney to write a lawyer letter or do something more?

Stacey Worthy:           

I would say if you wanna file a lawsuit, that’s a last-case scenario. If you need help with the entire process, you don’t necessarily need an attorney. You may be able to find a patient navigator. I know other groups—American Cancer Society offers assistance with patient navigators, who can walk you through the whole process and help you with the appeals process, and oftentimes, they provide those benefits for free. So, you don’t necessarily need an attorney unless you want to file a lawsuit.

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

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Page last updated on May 21, 2019