
<b>Insurance Companies</b>

<b>Petitioning for Insurance Coverage disputed treatments</b>

See the Center for Health Care Rights
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There is an organization called the National Patient Advocate Foundation that may be able to help / provide resources for patients with insurance problems, including problems with clinical trial coverage. They do advocacy issues.
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There is also an organization called the Patient Advocate Foundation.  It is a national non-profit organization that serves as an active liaison between the patient and their insurer, employer and/or creditors to resolve insurance, job retention and/or debt crisis matters relative to their diagnosis through case managers, doctors and attorneys. Patient Advocate Foundation seeks to safeguard patients through effective mediation assuring access to care, maintenance of employment and preservation of their financial stability.
Patient Advocate Foundation
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<b>Clinical Trial Costs</b>

B wrote:
The insurance company rejected claims for treatment for the ET743 Clinical Trial. We had our hearing last night. Even the local oncologists went to the hearing with us! I guess the next step is to appeal at the state level. Does anyone have any other ideas that we could use to get this covered?

B.
<b>1) Take a look at this NIH National Cancer Institute site
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2) If your insurance carrier is already covering clinical trials in other states, they may find it harder to reject your claim. Current list of states that require insurance companies to cover clinical trials costs.
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<b>Retiree Denied Sarcoma Oncologist Consult or Treatment. </b>

J wrote:
Dad is retired from Caterpillar and has an appointment with Dr. Demetri, the insurance company said they would not pay for ANY treatment or office visits...they said they wouldn't even cover surgery

J,
1) Ask your dad get the denial in writing including specifically (citing chapter and verse) why they say it isn't covered.
2) Review the Summary of Coverage booklet that's provided to every employee or retiree and see if the reason for denial matches the summary.
3) Most Summaries of Coverage make reference to the insurance contract between the employer and the insurance company. In most cases the employee or retiree is entitled to request a copy of the insurance contract. If not, then it can probably be reviewed on Caterpillar's premises. Review the contract.
4) Contact Caterpillar's Human Resources (Personnel) Department and see if they agree with the insurance company's interpretation of coverage. If not, they should help your dad get the decision reversed.
5) Was your dad a union man? If so, the union will help him.
6) See if your state's insurance department will help. What state does your dad live in?
7) See if you can get any help from the Patient Advocate Foundation. 

<b>Patient Advocate Foundation</b>
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Patient Advocate Foundation
help@patientadvocate.org 
700 Thimble Shoals Blvd
Suite 200
Newport News, VA 23606
Phone: (800) 532-5274
Fax: (757) 873-8999


<b> Case Managers </b>
J,
Also check with your insurance and with your benefits dept. LMS is complex enough that often you can ask for, or insist upon, a case manager. Here is a little excerpt from a friend of mine at a national insurance company:

Just wanted to send a few tips on working with your health plan and requesting a case manager.
If your health carrier is the same carrier that you had when the patient was originally diagnosed and treated, you should have a very easy time persuading the health plan to assign a case manager. You may even get the same nurse. If not, you might want to put together a written request for the current health plan, to document the original treatment plan. Just remember to stay as calm and unemotional as possible.
They'll know how urgent this is and work with you to find the best solution.
Many health plans automatically assign a case manager to complex cases.
I'd suggest calling the health plan and finding out how to contact case management directly to determine whether they have an automatic assignment protocol, or if you need to request the case manager.

Check with Customer Service and or case management to find out how to select or help in the selection of an oncologist. Find out if you are absolutely restricted to a limited network of physicians, or if you can seek services from a wider network of physicians. You may want to do a search to find out if there are resources available to help you shop for a specialist; look for personal recommendations, and don't be afraid to schedule an interview process.

If you're contemplating alternative treatments, ask whether any alternative/eastern medicine services are covered, or if there are any discount relationships with alternative/eastern medicine practitioners available. Blue Cross and Blue Shield of Minnesota has recently established an alternative medicine network of providers with whom the plan has negotiated discounts for services. Minnesota subscribers can access alternative services directly, without a referral, for the negotiated discount amount. California is so far ahead of the Midwest on this stuff, its possible that your health plan has a similar arrangement.

Ask the patient's current physician if he/she is comfortable working with you to find the specialists that you are confident about. Ask him/her to recommend a specialist that they would select if they or a family member needed services. Good bedside manner is nice, but you may want to make sure that everyone understands that you want honest, complete information.

Speaking of complete information, Mayo Clinic has a website, and they allow you to register and ask questions of the specialists. They might even be able to make a recommendation on specialists in your area. It might be worth your while to investigate this resource, if you haven't already.
If you hit a total roadblock,<b> find out what the patient rights are in your state. Every health plan has a patient/member bill of rights, and many of them are based on state mandates. Find out if there are any advocacy groups in your vicinity, and check with the Commissioner of Insurance for the state, to find out if there are any mandated appeal provisions at the state level that you could pursue.</b>
