Pat’s Place: Tips For Maximizing Health Insurance Coverage
Whether you agree or disagree that private insurance and Medicare should always pay for every necessary multiple myeloma-related medical procedure or treatment, it’s clear that they don’t always.
The key word here is “necessary.” The insurance company or Medicare may not agree with what you and your doctor feel is necessary.
The example I used in last week’s column illustrates this perfectly. Although Revlimid (lenalidomide) is not yet approved by the U.S. Food and Drug Administration (FDA) as an initial treatment for multiple myeloma, it is often prescribed for newly diagnosed patients.
At first, insurance companies commonly refused to pay for Revlimid use in newly diagnosed patients. But over the past five years, so many doctors have prescribed the drug that it has become customary for insurance companies to cover the prescription.
Customary, but not a guarantee. Because the vast majority of U.S. insurance companies have the right to refuse payment for drugs that aren’t FDA approved for a particular application, this issue still comes up from time to time.
Chances are an appeal will work in this case—but not always—making this a perfect example of how a patient, or patient’s physician, should always clear the use of any expensive medication or procedure with their insurance company or Medicare before proceeding.
OK. We have established that insurance companies sometimes refuse to pay for all or part of a drug or procedure on the grounds that it is “experimental”—code for “not FDA approved.”
But sometimes they can deny coverage based on arbitrary rules. A perfect example of this is Medicare’s policy of only paying for a single stem cell transplant.
Is this rule rigid and outdated? Probably. But understanding this rule can help a multiple myeloma patient save tens of thousands of dollars.
I know several patients who decided to transplant in their early 60s, with the thought that they would then be entitled to a second transplant, paid for by Medicare, after they turned 65.
Europeans and Canadians are familiar with arbitrary coverage limitations based on efficacy and cost. But many Americans fear this type of restriction, even though it already exists in our health care system.
This is one of the reasons the newly enacted Patient Protection and Affordable Care Act, often referred to as “Obama Care,” is still opposed by a large minority of American voters.
I bet you are thinking, “Great! Now Pat is going to get into the controversial political stuff he promised us last week!”
I hate to disappoint you, but not so fast! I’ll get to the all-important question, “Is treatment for multiple myeloma a privilege or a right?” next week.
For now, I would like to provide you with a list of a few insurance-related tips that have helped me over the years:
- Review your policy. Spend an hour or so trying to read and understand the fine print.
- Meet with your insurance agent. Keep him updated. Call with questions or when you feel that you aren't being taken seriously by your insurance company. My agent took the time to meet with me after my initial diagnosis. He helped me understand my policy and successfully fight the insurance company when I was denied coverage for my early chemotherapy and later my stem cell harvest.
- Enlist your doctor’s help. I find it helpful to get to know his or her nurse. Be polite and courteous. Develop a relationship. Most health care professionals are in the business because they want to help the patient.
- Non-profit groups like the Patient Advocate Foundation are often available to help.
- Know the law. What consumer protections are offered by your state? Does your state have an insurance review board?
- Don't give up! A recent Kaiser Family Foundation study found that over 50 percent of all denied claims were later paid.
- Patients who continue to press, even after a second or third denial, are often successful. I even know patients who appealed clearly-stated rules and policies and won!
- Keep good records, and be persistent!
You shouldn't have to do all of this extra work. It isn't fair! But it is one way to keep your health care costs down.
Next week will be devoted to the billion dollar philosophical question: Is treatment for multiple myeloma a privilege or a right?
Feel good and keep smiling! Pat
Pat Killingsworth is a multiple myeloma patient and columnist at The Myeloma Beacon.
If you are interested in writing a regular column to be published on The Myeloma Beacon, please contact the Beacon team at .
Pat: Well thought out plan for dealing with the insurance companies and Medicare. Thanks.
I think you may have erred with your political statement that a large minority of the voters oppose Obama care when you meant to say a large majority of the voters oppose Obama care. Looking forward to next weeks column.
Good two articles on insurance thus far. Cannot agree more on the importance of understanding your coverage, knowing your options, and communicating with doctors, agents, etc. A couple additional things I've discovered: 1) In most cases, your treatment center has people that can work with you and the insurance to navigate what's covered and what's not. In particular, I found that I could get few answers from insurance unless I had the insurance codes for the procedures, drugs, etc. being submitted. The center's office was very helpful coordinating this - usually workin directly with the insurance company to confirm coverage; 2) Confirm coverage before getting treatment. I recently had my stem cell collection performed, and they wanted to use Mozobil (~$17,000 per injection). They indicated it was usually covered, but I indicated I would not accept it until we had positve confirmation it was covered. Fortunately it was, since I ended up getting two injections over three days. I've also become much more concerned with health care coverage for everyone, particularly those with significant cost like ours (I'm over $150,000 so far this year). I'm fortunate to have good coverage, but I don't know how people without it can handle it. Take care, and good luck with your continued recovery from the SCT.
Here is another tip, if you are still working and with a large enough company that has an Human Resources/Benefits Department. Contact them immediately. They often KNOW exactly what your coverage is because they negotiated it. Our HR Dept got involved because my husband didn't have his insurance card when he went into the ER at the hospital. She stayed involved with me and and made sure that I had a Stem Cell Coordinator to deal with directly. When I mentioned to her that I had contacted them but they didn't seem to interested or that helpful, I got a call the next day from my NEW SC Coordinator. She stayed on top of everything and often shot me an email to ask how things were going with Dave. When we needed procrit and Dave had mistakenly taken the script to the local Walgreen's only to have it available for $2K a shot, she contacted a specialty pharmacy for us to manage it and we got everything for $40.
Another good tip, Lori. But I do know some people try to keep the whole thing secret for as long as possible. Afraid of losing their jobs?
Hey Gary, it depends what pole you read and what station you watch!
And I'm so glad you have good coverage... Me too! One reason my wife took her poorly paying job was the great health care coverage. I kid her about "how much she made" this year... Looks like she got a really big raise!
I do not want to get into a political debate with Gary but it is a LOUD vocal minority. My insurance company (Blue Cross) assigned me a case worker and she has helped me with any problems that I have had. It would help many people to get someone assigned to them to get them through many of these issues.
I can't wait until next week! Political debate will be encouraged! Great point about having a case worker/advocate assigned, Richard. Thanks- Pat
I am curious about part D coverage through Medicare - If the policy coverers Revlimid do you pay a co-pay or a percentage of the cost
Betty - You will have to check with your Part D plan to find out their specific rules. However, I believe it is the case that, in the case of most Medicare Part D plans, the patient has to pay a percentage of the cost of Revlimid, rather than a flat copayment.
It may still be possible to find Part D plans that have flat copayments for expensive drugs like Revlimid, but, as I said, I think most Part D plans currently require a percentage payment.
Betty-
I decided to pass on Medicare and use my wife's insurance at work instead. But while I was shopping around and still considering it, I specifically asked supplemental plans how they classified Revlimid and what the cost was. Wide range of answers! Worth checking, because most every myeloma patient will use thalidomide or Revlimid at some time--and pomalidomide is on the way--that's oral, too. Oral Velcade may be available in a few years, also. By then, if ObamaCare isn't overturned, there won't be a donut hole anymore, which will make it all easier and more affordable. Oops! You mean the new program does some good things for cancer patients? You bet! Pat
Pat: My husband also "passed" on Medicare, because I was still working and covered him, with my insurance. As a result, Medicare imposed a monthly penalty when he did sign up (even though he had saved Medicare $$$ by having other coverage). Just make sure they understand what you're doing - and get something in writing!
Betty: The distribution pharmacy, that shipped the Revlimid to us, contacted our Part D plan to determine what portion the plan would pay. They (pharmacy) also put us in touch with the Chronic Disease Fund, which assists with picking up some of the high cost of the drug. The problem is that the high cost of the oral drug immediately pushes you into the coverage gap (donut hole).
Cancer is costly in every sense of the word!
Another great post, Pat.
Hi Sarah-
My understanding is that it is OK to pass on Medicare as long as the insurance you choose is as good or better. Are you sure you can't challenge that? From what I read, you didn't need to do anything up-front--just after you decided to enroll. Can you share any details? Thanks- Pat