Dealing with Insurance Companies as an Oncologist: How Has the Process Changed?

As cancer care becomes more expensive, many patients rely on their health insurance to afford the already-high, and still rising, costs of treatment. CancerNetwork® spoke with Loretta Nastoupil, MD, about how the physician-insurance company interaction has shifted over the years that she has been an oncologist.

Initially, she noted that there are more barriers to pursuing an approval. Oncologists and their staff, particularly at community cancer centers, are forced to remain determined in getting approval from these companies. While most providers stick to the NCCN guidelines that enforce standards of care across various disease types, Nastoupil noted that even considering those standards, it may be more difficult to get the insurers to agree. Specifically, more modern therapies, like Bruton’s tyrosine kinase (BTK) inhibitors, can require more work to get the insurance companies to improve.

Nastoupil, a practicing oncologist at Southwest Oncology in Durango, Colorado, iterated that it’s crucial to remain patient and endure the wait times necessary to get proper approval for the treatments that can provide patients the best experience possible. These insurance companies and payers, as she said, are aware that they have the luxury of time, whereas oncologists and patients do not.

Have you noticed any differences when dealing with insurance companies over the years you’ve been practicing?

There appear to be more barriers instituted to see if you have the staff or the determination to stick with it, or if you’ll potentially quickly move on to something that’s potentially more financially feasible. Most oncologists will rely on NCCN guidelines to know what is essentially a standard-of-care option. Payers and insurers will also look at that as the standard of care. Most of your practicing oncologists in the community are going to fall within those guidelines, and they’re generally not asking for things that are not FDA-approved or outside the window of being a standard-of-care option.

Even with those guardrails, we see that with some of our more modern therapy, particularly in the form of oral targeted agents—BTK inhibitors, for instance—you’ll see that it often takes longer for insurers to even agree to it. That’s even before we learn what the patient’s copayment is or what their responsibility might be. If you don’t have the patience or the luxury of time with the patient in front of you, it’s sometimes easier to move on to that standard chemotherapy option that’s been around for many years because you know you’ll potentially get it approved faster. That’s where the practice of oncology has probably changed the most over the last 10 years.

You have to understand that we need to have patience on our side and we need to have patience with our staff who are negotiating on these payment plans, but you also need to manage the patient and their family’s expectations. That’s where people start to cave under the pressure in most situations, because it’s so much communication and a lot of managing what a realistic wait time is vs what’s unacceptable. But you’re also doing that when you’re busy seeing patients in front of you. That’s where payers and insurers know that they probably have an upper hand because they have the luxury of more time, they’re not patient-facing, and they don’t have to deal with the questions every day of why this is taking so long.