PEER REVIEWS, OTHER FOLLOW-UP CAN HELP WHEN INSURANCE CLAIM IS DENIED
Q: From rising premiums to claim denials, health insurance is a controversial topic right now in Oklahoma. As an oncologist, how is this affecting your profession?
A: Insurance can be one of the most complicated parts of treating a cancer patient already battling a tough situation. Oklahomans would be surprised just how often insurance claims are denied for many types of cancer treatment, including proton therapy. When a patient is denied coverage, treatment delays and financial concerns add further stress to an already unfortunate circumstance.
Q: In a recent American Medical Association physician survey, 92 percent of participants reported care delays by their patient’s insurance company. What avenues do you take to advocate for your patients?
A: We start by talking to the insurance company’s medical director by telephone in what is referred to as a peer-to-peer review. If coverage is denied at this point, we will submit detailed letters with comparative treatment plans and reams of documentation explaining the necessity of using proton therapy for the patient in question. Ideally, we get their case reviewed by someone not associated with the insurance company, who therefore doesn’t have a vested interest in denying their coverage. Finally, the Oklahoma Insurance Department may request an outside review by an impartial specialist. This process can often take 30 to 90 days or beyond.
Q: Proton therapy can be deemed as unnecessary by many insurance companies such as Blue Cross Blue Shield of Oklahoma. What reasons are given?
A: Unfortunately, Blue Cross Blue Shield of Oklahoma and many other private health insurers have begun cherry-picking treatment options as “not medically necessary.” Blue Cross Blue Shield of Oklahoma recently denied proton therapy radiation for one of my breast cancer patients with the reasoning that “the usual and customary treatment for (her) cancer is 3-Dimensional Conformal Radiation Therapy,” basically saying it is their standard level of care and most likely the cheapest option. I can usually make that option work for most patients, but in her case, the “standard treatment” would give 10 times as much radiation to her heart as proton therapy. They are unwilling to make an exception based on her specific anatomy and the extent of her cancer. Insurance companies often claim that proton therapy is experimental, which is simply not true. In fact, the U.S. Food and Drug Administration approved proton therapy in 1988 as another form of treatment for cancer patients and it has been used since its first medical application in the mid 1950s. To date, more than 150,000 people worldwide have received proton therapy at cancer centers worldwide. Oklahomans buy and pay a high price for health insurance to protect them from life’s unexpected circumstances. This is their job, and I want to be able to do mine.