When it comes to reimbursement for cancer treatments, the brave
new world of managed care may seem like the La Brea Tar Pits.
Through its Ombudsman program, the Candlelighters Childhood Cancer
Foundation has made it a top priority to help families of childhood
cancer patients navigate this treacherous terrain. At the Foundation's
25th anniversary conference, Grace Powers Monaco, jd, mentor to
Gib Smith who directs the Candelighters Ombudsman Program and
Director of the Medical Care Ombudsman Program of the Medical
Care Management Corporation, described some sure-fire methods
for prying money out of recalcitrant insurance companies.
"Managed care makes it difficult for families that often
have complicated health technology care needs," said Monaco.
But even something as simple as the ill conceived language in
a letter to the insurance company can sink a claim. In any correspondence,
the doctor, if medically possible, should echo the criteria outlined
in the insurance contract, said Monaco.
Moreover, certain words are almost guaranteed to kayo a claim.
In one case, it finally became medically possible to reconstruct
a survivor's orbit years after she'd had retinoblastoma. The doctor
mentioned in the correspondence that "this will have a wonderful
cosmetic effect," said Monaco, and "that one word kicked
the whole thing in the dumpster." (Candlelighters intervened
and an "enlightened" and grateful company agreed that
surgery was medically necessary.)
"Your doctor must not use the words 'experimental' or 'investigational'
in any correspondence," Monaco emphasized. "Compassionate"
is another word that will certainly undermine eligibility, said
Monaco, because the insurance company will automatically assume
it refers to a compassionate IND (investigational new drug) and
deny it as experimental.
If a child is receiving treatment through a clinical trial, that
does not necessarily mean the treatment is experimental, Monaco
explained. "It may not even be in the nature of investigational.
Usually a POG or CCG protocol is involved and the docs are certain
that the therapy is going to benefit the child; the head-to-head
[comparison] is just fine-tuning. We know the therapy is going
to benefit the child."
Defense Against Insurance Company Foot-Dragging
One great defense against insurance company foot-dragging is what
Monaco called the "getting smart parent syndrome." When
a claim is denied because a treatment allegedly is experimental
or investigational, the parent should write a letter to the company
asking why. The letter should ask for citations to the policy
language, the company's rules and the literature that was relied
on in denying the claim.
On top of that, request the names and curriculum vitae of any
physicians reviewing the treatment, internal or external to the
company, Monaco advised. "You may get a phone call in 2 days
saying, 'Oh, we made a mistake.' The company is acknowledging
that they didn't investigate your claim (which they have an obligation
to do) or they had it reviewed by someone unqualified to review
"Sadly, there are some few companies that deny everything
unless pushed," she added. "If coverage is denied after
reason and pressure, don't be discouraged; if we have the case
reviewed by independent pediatric oncologists and they agree that
the care is medically necessary, dollars to donuts, we can get
it paid for. Even specific exclusions for bone marrow transplants
may be beatable."
Even denials of coverage for very new treatments do not have to
stand, said Monaco. "The literature they [the companies]
rely upon is 6 months to 2 years behind what your cutting edge
docs know about. We have had a variety of cases where we knew
that articles would come out in the next 6 months that would demonstrate
that what your child was going to get is the standard of care.
The physicians got permission of the authors to have the data
released to us to share, under agreement of confidentiality, with
the health plan."
The bottom line, according to Monaco, is that "it is not
the intent of companies to preclude coverage of medically necessary
treatment.Therefore, if their policy language is such that it's
behind the times and a treatment has become recognized, or standard
of care, we have found they will listen to reason and include
The Candlelighters Childhood Cancer Foundation is located at 7910
Woodmont Avenue, Suite 460, Bethesda, MD 20814-3015; phone: 800-366-2223
or 301-657-8401; fax: 301-718-2686.