Insurance

 Hospitals and Health Care Providers

Health insurance pays for medical expenses. Health insurance is complicated and often drives your cancer treatment. States have regulations which force health insurance providers to cover certain procedures. To access state departments of insurance to verify mandated coverage visit:

National Association of Insurance Commissioners

Read your policy carefully, including the fine print and pay special attention to the following areas:

• Are your doctors, hospital and other providers in your plan?
• CONFIRM ALL PROCEDURES, TESTS , CANCER TREATMENTS and MEDICAL PERSONNEL ARE COVERED BY YOUR INSURANCE BEFORE ANY CARE IS INITIATED. A breast cancer surgeon may be in your network but an anesthesiologist may not. You can confirm by phone.
• Understand the terminology in your policy.
• Confirm if pre-authorization (permission from your insurance company) for a hospital stay or outpatient cancer treatment is necessary.
• Save all bills, payments and insurance statements for four years.
• Keep a list of all health care provider visits by date and record your co-pays on         Breast Cancer Advocate iPhone App.
• If a claim for cancer treatment is denied, appeal it.

Definitions

The following are key terms to basic understanding of your insurance policy:

• HMO-Health Maintenance Organization. A form of managed care where medical professionals offer care for a flat monthly fee. However only visits to physicians who are members of the HMO are covered. All care, prescriptions, etc. must be cleared by the HMO. An HMO primary care physician handles all referrals.
• PPO-Preferred Provider Organization. A form of managed care which provides more flexibility in choosing medical personnel. You can see physicians and health care providers who are not participants in your PPO but your out-of-pocket expenses will be higher.
• Point of Service- A form of managed care. A primary care physician coordinates patient care but there is more flexibility in choosing health care than in an HMO.
• Indemnity Health Plans-Traditional plans where an individual pays a percentage of medical costs and the insurance company pays the remainder, after a yearly deductible is met.
• In-Network- A group of health care providers who participate in a managed care plan.
• Out-of-Network-A group of health care providers who do not participate in a managed care plan. If a patient goes out- of-network, the patient will pay a larger percentage of the costs.
• Co-Insurance-The amount the patient pays after the yearly deductible is met.
• Co-pay- The flat fee a patient pays each time he/she receives medical care.
• Maximum Out-of-Pocket Expenses- A pre-determined amount of money a patient must pay, before an insurance company will pay 100 percent for an individual’s health care expenses.
• Maximum Dollar Limit-The maximum an insurance company will pay within a specific time period.

Tips to Wade Through the Tangle

Record keeping and bill management is extremely frustrating but critically important. Many hospitals and clinics employ a representative to help you.

• Get a copy of your insurance policy and know what it covers.
• Always keep your insurance card with you and the phone number of your customer service rep.
• Designate one credit card and charge medical expenses only to that card to easily track provider payments.
• Organize and file all your covered expenses, claims, denials, and appeals. Do not throw anything out. ORGANIZE ALL BILLS, RECEIPTS AND INSURANCE STATEMENTS BY DATE OF SERVICE.
• Call your insurance company with questions. Insurance companies often cover some in-home care, durable equipment(wheelchairs, walkers, etc). It never hurts to call and ask.
• Keep a running log of all conversations with your insurance company, including the following information. If you’re unsatisfied with a representative’s response, ask to speak to a supervisor.
  • date
  • time
  • topic
  • representative’s name
  • number called
• If you disagree with the insurance company’s reimbursement decision, you have a right to appeal their decision. If your insurance company refuses your appeal, you can contact the state insurance commissioner or file a lawsuit. The following items should be included in your appeal:
  • a formal appeal letter
  • a letter from your doctor justifying the treatment you received
  • pertinent info from your medical records
  • supporting information from medical journals.

For more more comprehensive insurance information, go to:

Healthwell Foundation for financial information and help covering co-pays, premiums and coinsurance.

Cancer Care for general insurance information.

Health Insurance Resource Center for a glossary of insurance policy terms.

The American Cancer Society to learn what records should be kept for insurance.