The steps for insurance approval
Talk to your doctor about proton and photon radiation treatment.
If you decide to choose proton, decide on where you will get treatment.
If you are travelling out of state for treatments, how will that state’s insurance laws effect your insurance approval?
During your meeting with the Radiation Oncologist, ask about the insurance process.
Ask the doctor or the person handling the insurance at the radiation center:
How much does proton treatment cost?
If I elected photon treatment, would it be less expensive? In Denise’s case, proton and photon radiation were the same price-cost neutral.
Ask how long the insurance approval will take.
Ask about the peer to peer approval and appeal process through the insurance process.
If treatment is delayed due to insurance talk to your oncologist. Denise’s oncologist’s office was kept in the loop and told her: “For every week you delay getting treatment and working through insurance, your risk for re-occurrence increases. You need to get treated and make a decision.”
Denise’s experience with United Healthcare was rough. Here’s her story in her own words.
Despite my doctor’s peer review appeal, United Healthcare declined my claim for proton therapy once -then twice. After the second try Doctor Eblan called and told me United Healthcare declined my appeal again. United Healthcare deemed the treatments; “not medically necessary.” Yet, Doctor Eblan said he wanted to submit a third appeal and in the meantime I decided to advocate for myself.
I called customer service at United Healthcare. The person I spoke to was distant and I felt like a transaction not a person. She didn’t represent someone that was in a customer “care” position for health”care”. The service representative said my claim was denied and she couldn’t help me. Yet, I already knew my claim was denied twice. After all, that is why I called to talk to her. It was extremely frustrating to me.
I remained calm and told her I talked to my doctor and I already knew it was declined. I wanted to know why my claim was denied despite medical evidence that I needed this treatment. I asked the service representative for the doctor’s name that made the decision to deny my claim. She said, “I can’t tell you their names, but you can ask your doctor.” So in the end, she recommended that I talk to my doctor. She also told me I could appeal my case and fax a letter to United Healthcare. I asked her for an email address. She said they didn’t have one which was frustrating to me. I imagined a fax machine with letters piled up from patients just like me. I went full circle with this customer care person only to be told to call my doctor and ask him why it was declined; which of course I already knew.
But these were not her rules, these were the rules of the insurance company. In fact, I am not sure why they call this department customer service-she didn’t provide service to me. She frustrated me as I battled cancer. People kept saying, “stay strong.” I felt strong, I even put my Boston Strong t-shirt on and followed my friend Lees advice; “keep your helmet on.”
My doctor didn’t give up
I started writing to my friends and family again; “Can anyone help me? Does anyone know anyone who has had proton therapy treatment or does anyone know anyone at United Health”care?” Someone on the breastcancer.org site told me her her treatment was approved for breast cancer, but she didn’t have United Healthcare.
After a third try and eight and a half weeks after my mastectomy, Doctor Eblan got my case approved! He worked with Allison Scull at the Maryland Proton Treatment Center and submitted a nine page peer to peer review about my case. My cancer treatment was delayed which isn’t good. But we fought to get it approved by insurance. I am so grateful for Doctor Eblan and Allison Scull. From my perspective this peer to peer process was ineffective. I don’t even think my radiation oncologist spoke to a radiation oncologist until the third try. How can this be a “peer to peer” review if the doctors are not practicing the same medicine?