<b>Your loved one needs a treatment or a consultation, your insurance company or HMO refuses.  What do you do?</b>

<b>A. Case Managers and Social Workers and Doctors' Assistants</b>
1. <b>Social Workers </b>are often excellent patient advocates.  They not only know how the system works, they know how to work it.  They can ease many situations by getting things done.  One couple advises that whenever they were referred to a new facility, one of the first things they would ask was to contact the social worker.  They would introduce themselves, explain their situation, and tell the social worker they would call on them when needed.  And the social worker always seemed to come through when we needed them.  It was not an additional cost to use the social workers in the various facilities, and they WANT to help.  They would recommend contacting the social workers and asking them what they can do for you.

2. <b>Case Managers</b> are often R.N.s or nurse practitioners. Insurance companies or HMOs sometimes have them working for them.  Ask to have a case manager assigned to your case.  This means that one person will understand what needs to be done, and can get your needs seen to within the rules of the insuring organization.  She will be the person you contact for all problems and requests.  

3. <b>Doctors' Assistants</b> are R.N.s or nurse practitioners.  They are useful in getting the tests, letters, or recommendations that you need.  

All of the above work as patient advocates, and can help when things seem to fall through the cracks.  


<b>B. The Patient Advocate Foundation</b>.

You need to have your ammunition in place, but the &&url which can also be contacted at 800-532-5274 has "scripts" on how to deal with your insurance company to get their approval.  It is a useful resource.  The Patient Advocate Foundation has<b> &&url </b>in .pdf files - including <b>Managed Care Answer Guide</b> and <b>Your Guide to the Appeals Process</b> 
&&url - Physicians, Attorneys, Advocates 
&&url


<b>C. General Approach in Dealing with Insurance Carriers [by Richard, caretaker husband] </b> 

	My wife is a rare cancer survivor.  I work closely with patients and physicians that treat this disease and unfortunately I have had to battle each of the majors for my wife's treatment -- Prudential, Aetna (you bet ya), and Cigna.  I am a scientist and have managed in business for many years.  I am not a physician.  The opinions I express below are based on my personal experience in fighting insurance carriers to keep my wife alive.   

You need to confront them with the material BUT <b>get really prepared and BE SURE this is the only treatment that holds reasonable promise before you start on this path.  Once that is determined then RAISE THE STAKES TO THE HIGHEST LEVEL.  Your life depends on it. </b>
Some points based on my past experiences. 

<b>1.  Have at least two (2) doctors' letters advising that this is the only treatment that might save your life. 

2.  Get the stats on your cancer and mets and lay that out on paper 

3.  Put the specifics of your case on one page. 

4.  You will have an insurance company case manager - get their name and the name of the Medical Director for the area that serves you. 

5.  Get your employer benefits director involved if you are employed.</b>  If you have a large employer that is really good because the insurance carriers listen better.  Remember insurance companies don't give a damn about anyone.  It is all about money to them and that's what they understand.  This is a war for your life.   You have to make the price of their denial intolerable for them!!  I cannot stress this enough. 

<b>6.  Try to find out if the denial was done by a nurse (which I bet it was).  If so you may have them for practicing medicine without a license as a physician.  Keep that in mind. 

7.  Pull the latest data on the treatment you want. </b> Whether it says that it is less invasive, and that it can be essentially a very short stay in the hospital for the procedure.  Get the facts and make sure you know what the procedure will cost versus any other possibilities if there are any. Why it is the best for the situation.  Or why it is more cost effective.  Quote the medical literature.  

<b>8.  Pull all that together and make these points: 

a.  Only way to save your life  
b.  Rare cancers/NCI suggests clinical trials etc.  
c.  You have documented your physician's recommendations that this is the procedure that should be done.  
d.  It is cost effective. [Ineffective treatments are not cost effective because of treatment of recurrence, so if this treatment has advantages in effectiveness, but costs more, the effectiveness should be emphasized.]

9.  Right before you send it get with your local State representative in your State and your Congressman.  CC them on the letter. 

10. I do not know what State you are in but suggest you call the Attorney General's Office AS WELL AS the State Insurance Board for assistance. </b> (Let them help you fight if they will - in Texas they are banging the hell out of the insurance folks and they listen because they have been repeatedly fined!)  They should be copied in on the letter also. 

<b>11. Consider "site appeals". </b> For instance, if the FDA has only approved TheraSpheres on the basis of a "Humanitarian Devise Use" in the US for Hepatocellular Carcinoma (HCC), then consider a site appeal, that is liver site.    The TheraSphere Docket and exception is FDA # H980006.    It was provided to MDS Nordion, Inc. maker of the TheraSphere, Ontario Canada. 

<b>12. *** Make it a national issue after that and petition Nordion and the Canadian government to allow the procedure to be done in Canada and get your Congressman and Senator involved.  CC them on every correspondence. </b>

<b>13.  Bottom line, wake their butts up that you are in danger of losing your life if you cannot get this treatment and they will be responsible for that outcome. 

14. Document everything and I mean EVERYTHING related to your case. 

15. If you send them a letter keep it somehow on ONE page and send by certified mail with appropriate copies to above:  benefits; state rep, state senator, US Congressman, US Senators, State Attorney General, State Insurance Board, Doctors who you have a letter from.  (Attach their letters). </b>

<b>I have yet had this general methodology fail.   Go to the top right away, don't screw around with the worms answering the phone.   Richard</b>  


<b>D. Insurance company websites:</b>
Here are some consumer oriented websites:

&&url

&&url

&&url

&&url - Under "Resources" has a "Managed Care Resource
Guide" to help answer questions in selecting an insurance plan.
 

compiled by doctordee
February 2003