Five Quick Steps for New Cancer Patients1. Obtain your medical recordsObtain and organize your medical records. You are entitled to all written (transcribed) copies of your medical reports including your lab tests, pathology, operative and radiology reports, as well as copies of your CT or MRI scans on CDs. You may obtain copies of all these reports from your hospital, clinic, or doctor’s office(s.) Having one’s own medical records within arm’s reach (stored in file folders, a binder, a USB “thumb drive” etc.) is not only comforting to many patients, but practical, especially in emergency situations or while traveling.2. Understand your diagnosisMost patients are not healthcare professionals, therefore many patients feel overwhelmed when reading their own medical reports. Terminology may be confusing. It’s easy for the nonprofessional to become distressed by nomenclature (refer to our Appendix Cancer Glossary) when reading one’s own medical reports. Now that you have obtained your medical records, including your pathology report, develop and refine your list(s) of questions to discuss with your physician specialist. The PMP Pals’ Network Handbook: Questions to Ask Your Surgeons provides sample lists of questions.Although you share a diagnosis with other patients, each case is truly unique and each patient is an individual, therefore, your case deserves personal consideration by whichever specialist(s) you consult with.3. Assemble your healthcare teamYour team may include a variety of healthcare professionals including an oncologist, surgical oncologist (the true specialist in the treatment of appendix cancer, Pseudomyxoma peritonei and other Peritoneal Surface Malignancies.) Following surgery and during chemotherapy, your healthcare team may include a gastroenterologist, endocrinologist and a licensed dietician. Ask your team of healthcare professionals to communicate among one other regarding their participation in your treatment plan. Don’t forget to include your dentist on your health care team!4. Examine your health insurance Examine your health insurance policy carefully. Are the most qualified, most experienced physicians specializing in the treatment of your diagnosis covered by your plan?Review your insurance plans policies for co pays, deductions, home nursing assistance, lifetime maximums, etc.Pay close attention to pre authorization and certification requirements before scheduling any medical procedures and treatments including tests, scans, surgery and chemotherapy. Review your medical bills carefully, checking for diagnostic code or other billing errors.While some health insurance providers staff case managers to “assist” you in managing your treatment plan, ask yourself, “is this case manager advocating for me or for my insurance company?” Our advice is to serve as your own advocate, or to appoint a close trusted family member or friend to co advocate with you. You need to put your needs first!5. Protect your privacyWhen you are newly diagnosed or in the midst of treatment, it may be tempting to open your heart or vent your feelings online, but be aware that anything you post via social networking can be viewed by others and can be easily intercepted. The angst and details about your medical condition you post today can be read by current and future employers, creditors and nosy neighbors tomorrow. Do not post information about your minor children, the location of your home, the duration you will be away from home for medical care, etc., online, especially via social networking on “care” page forums, as this information can be intercepted and seriously abused.
Articles posted in PMP Pals and on www.pmppals.org are written from the perspective of patients and family caregivers and are not intended to substitute for professional, licensed legal and/or healthcare advice. Patients should seek the counsel of their licensed professional consultants regarding their specific needs. Copyright © 2012 by PMP Pals’ Network/Gabriella Graham/All rights reserved. Visit us on the web at www.pmppals.org
Filing an appeal when you insurance claim has been deniedBefore scheduling treatment, check for the following:Does your plan provide out of network coverage?Is your provider an HMO (Health Maintenance Organization)?Is your provider a PPO (Preferred Provider Organization)?Keep your health insurance card on hand. The card includes identifying information about your policy, including co payments.Before you get started with the appealing the denial of coverage, check for the following:Policy exclusions and restrictionsDenials may be made because the policy specifically excludes coverage of a certain treatment, procedure or medicine. Contact your insurer’s case management department to confirm whether specific costs are covered (ideally, this should be done before you are admitted to the hospital for treatment.)Organize your paperworkOrganize all the information you need from your insurer before you start the appeal process. The "explanation of benefits" should provide a code for the reason your treatment(s) was denied. If you cannot locate the code, ask your insurer to provide it.Notate the name, date, time, phone number, and extension of each person you talk with, whenever you call your health insurance provider.Find out exactly to whom the appeal should be addressed and mailed. Keep copies of any written correspondence and send it via registered mail, requesting a return receipt. Clerical and coding errorsCheck to see whether the denial was due to a clerical or coding error. If the denial was due to an error, have your hospital, or physician's billing clerk, correct the error and provide you and the health insurance provider with a corrected copy of the bill, with the correct code.Reason for denialSpecifically, why was your claimed denied? Follow the guidelines of the “denial letter.” Customize your appeal, specifically for the reason your claim was denied. Time limitationsMost insurers set aside a time period during which a patient may file for an appeal. Check your policy to determine this time limit, which may be 60, 90 or 180 days. Monitor time limitations so you don't miss the deadline for your appeal. Emergency Out of Network CareCoverage/reimbursement of an out-of-network emergency claim, will require proof 1) Of the medical emergency and2) Confirmation that no in-network provider was readily available, within reasonable proximity of the emergency. Use your emergency medical records, with doctors' notations, to support your claim."Experimental" Protocols/TreatmentHIPEC is more commonly denied for payment as “experimental” medical treatment among our fellow patients than any other protocol/treatment. The surgical oncologist who proposes treating you with HIPEC should be your first line of defense for this type of denial. He/she should be prepared to provide you with a letter stating that HIPEC (or any other treatment being denied) is the established protocol/treatment method for your specific diagnosis. His/her letter can be accompanied by medical journal publications by that surgeon or others, as noted in the red Alpha Index section of medical journal articles posted on the Pseudomyxoma Peritonei page at www.pmppals.org State Appeals Review BoardsIf you receive coverage directly from an insurance company, your insurer is regulated by your state’s insurance department. With the exception of Alabama, Mississippi, Nebraska, South Dakota and Wyoming, patients in all other states are allowed to have their appeals considered by an independent external appeals review board. Generally, the review board consists of physicians and other healthcare providers with expertise in your disease. Contact your state department of insurance for more information.These departments are listed on the Health Insurance link at www.pmppals.org Additional assistanceAdvocacy groups will assist you at no charge. An extensive listing of patient advocacy groups is posted on the Health Insurance page at www.pmppals.org Articles posted in PMP Pals and on www.pmppals.org are written from the perspective of patients and their families and are not intended to substitute for licensed, professional, legal or medical advice. Patients should seek the counsel of their licensed healthcare providers. Copyright © 2011 by Gabriella Graham/PMP Pals’ Network/All rights reserved. Visit us on the web at www.pmppals.org