Bone and Marrow Transplant Information Home Page

From
BMT Newsletter
May1994
Issue # 23 - Breast Cancer
Reprinted by NYSERNet with Permission from BMT Newsletter

INSURANCE COVERAGE AND BMTS

by Richard Carter

(Richard Carter's firm Hudgins, Carter and Coleman in Alexandria, VA has handled more than 200 insurance reimbursement cases for BMT patients.)

Denials of insurance coverage for BMTs continue to be a problem and can be a source of tremendous frustration and anxiety, often coming just before a patient needs to be hospitalized.

The best way to minimize insurance problems, anxiety and expense is to start early. Since life gets much more hectic if an insurance denial comes at the last minute, it's important that you and the transplant center take the following few steps at the outset:

1. Get precertification for the BMT from your insurance company as soon as possible. The transplant center should contact your insurer early in the planning process so that the insurer can review the request and resolve questions. Make sure that your insurer's precertification means that it will provide coverage; some companies preauthorize a hospitalization but then refuse to pay benefits.

2. The hospital should set a target date for admission and communicate that date to the insurer at the time of the precertification request. This gives the insurer a deadline to decide whether to pay for the BMT, and gives the patient time to arrange for contingencies if approval is not forthcoming. Many transplant centers do not want to give the patient a target date because so many variables can affect the transplant timetable. Nevertheless, if a patient has to go to court to force an insurer to cover the procedure, it is easier if an optimum transplant time has been determined in advance.

3. The transplant center should send an information package to the insurer which includes a letter from the treating physician as well as studies and articles supporting the doctor's recommendation. The packet should include the name of a person the insurer can contact with follow-up questions.

The letter from the doctor should stress that the treatment is the best available therapy for the patient, is safe and effective, and is widely accepted by the medical community. For the most part, insurance companies with "experimental" or "investigational" exclusions in their contracts resolve the question of whether or not the procedure is reimbursable by looking at its safety, effectiveness and acceptance in the medical community. The letter ~}uld not be too technical; while most medical directors at insurance companies are physicians, some of the people who review the letter may not be.

Include articles and graphs that explain why the treatment plan is appropriate. Use the most current articles and studies. Older studies are less persuasive and usually report worse results.

4. Exercise care when sharing the protocol and your Informed Consent form with the insurance company. On the one hand, these documents provide detailed information about the treatment plan, and show that the therapy has been carefully reviewed and approved by an Institutional Review Board. However, protocols and Informed Consents are often the pretext used by insurers to deny coverage.

Federal law requires that these documents include information about the experimental nature of any procedure. Many institutions remove the experimental warning when it is no longer appropriate, but some do not. In those cases, the outdated language is used against the patient. You should scrutinize or have an attorney review these documents before providing them to the insurer.

5. Assemble all of your insurance information early. Get the latest copy of your Plan booklet, as well copies of any other policies under which you are insured ("secondary policies"). Don't settle for the few descriptive pages employers usually provide their insured; get the entire Plan booklet. If you must consult with an attorney, you'll will need to show him or her a copy of your entire insurance plan, since the most important parts are sometimes obscured.

By taking these steps, you can avoid most problems. However, BMT procedures are relatively expensive and, to some insurers, expensive is a synonym for experimental. If your insurer turns down your request for coverage, the next few weeks are critical.

The majority of insurance plans are governed ERISA, a federal law. ERISA limits your rights substantially and requires you to do certain things within certain time frames. Most importantly, you are almost always required to appeal your insurer's denial of coverage before proceeding to court. What you put in the appeal letter will determine your rights later should you have to go to court. Accordingly you should remember:

1. Most ERISA plans require that you appeal a denial of coverage within 60 days or you lose all further right of appeal. Many people are turned down at the last moment and go in the hospital figuring they'll deal with the insurance company after hospitalization and recuperation. A few months later, they are too late.

2. In most cases, when you go to court what is really being tried is the reasonableness of the insurer's decision to deny coverage, not the appropriateness of the therapy. If your appeal letter doesn't contain substantial evidence justifying treatment and your hospital didn't send the insurer any such information, you may be precluded from offering this evidence at trial.

3. The appeal letter should state why the procedure is appropriate. It should identify resources the insurer should contact, list any favorable second opinions received and how to contact the doctors who rendered them, list other doctors who believe this treatment is helpful, etc.

4. Your appeal letter should come from any attorney experienced in this area of the law. It should not be drafted by the kid just out of law school who helped with your house-closing. The appeal letter will be the heart of your legal case and needs to be carefully crafted. It should not threaten litigation, make conclu- sions without backup or insult the reader. Angry people are people who say NO.

Choose an attorney with the same care you exercised in selecting your doctors. Don't settle for one because he or she is closest or cheapest, although cost is a major consideration. Ask how they would handle your case and decide if you trust them and feel comfortable working with them.

Although many insurance companies support state-of-the-art care such as BMTs in a responsible and compassionate way, some are not honest in dealing with their insureds and act with blatant disregard for people who've faithfully paid premiums for years and now need their help. If you're refused coverage for a BMT, check with a lawyer to determine whether the insurance company's interpretation of the contract is correct or can be legally challenged.

author

This document was created by NYSERNet, Inc. through a grant funded by the New York State Science and Technology Foundation as part of the Breast Cancer Infomation Clearinghouse.