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Case Reviewers Can Help Resolve Disputes Re: Reimbursement

Case Reviewers Can Help Resolve Disputes Re: Reimbursement

HACKENSACK, NJ-- Tough economic times can be blamed for the current
game of roulette played by health-care insurers when it comes
to coverage of experimental or off-label treatments, said Grace
Powers Monaco, JD, director of the Medical Care Ombudsman Program,
Medical Care Management Corp. Bethesda, Md. But overeager physicians,
patients, and patient advocacy groups must also share some of
the blame for the current tug of war, she said.

Independent reviewers, such as Medical Care Management Corp.,
can often help resolve disagreements (see below). The company
provides case review services for employers, insurers, and managed
care plans on a fee basis, and pro bono for patients who cannot
afford to pay. Ms. Monaco is also founder of the Candle Lighters,
an advocacy group for parents of children with cancer.

The problem goes back to the early 1980s, when the federal government
stopped including patient support care costs in grants for studies
of new therapies, she said at a conference, sponsored by the Northern
New Jersey Cancer Center, Hackensack Medical Center.

By 1986, she said, payers realized that patient supportive care
costs were being passed on to them. They responded with more rigorous
enforcement of exclusion clauses, especially regarding autologous
bone marrow transplantation (ABMT) for adult lymphoma patients
and later for breast cancer and other indications.

Compounding the problem, Ms. Monaco said, was the tendency by
some physicians to oversell the case for ABMT. The media picked
up the story, and patients, many of whom were medically ineligible,
begin clamoring for transplants.

Unfortunately, some patient advocacy groups may be exacerbating
the situation, she said, "by always assuming that the patient
is right." As a result, physicians and patients may be at
cross purposes with each other," she said, pointing to cases
in which patients have inappropriately sued physicians for not
providing experimental care (see the first case history ,below).

Some physicians, perhaps out of fear of such lawsuits, have lacked
the courage to deny patients' requests for inappropriate treatments,
Ms. Monaco said. When the decision is made to go forward with
a costly experimental treatment, instead of facing economic issues
head-on before treatment, physicians may take the ostrich approach:
"Let's just bill the charges and see if they will pay for


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