Strategies
What can I do to increase the likelihood of coverage?
What if my claim is denied after I begin participating in a trial?
Where else can I turn for assistance?
There are several steps you can follow to deal with coverage issues up front
when deciding to enter a
clinical trial. Along the way, enlist the
help of family members and your doctor or other health professionals. You may
find the following checklist useful:
-
Understand the costs associated with the trial. Ask your doctor or the
trial's contact person about the costs that must be covered by you or your
health plan. Are these costs significantly higher than those associated with
standard therapy? Also, inquire about the
experience of other patients in the trial. Have their plans paid for their
care? Have there been any persistent problems with coverage? How often have the
trial's administrators been successful in getting plans to cover patient care
costs?
-
Understand your health plan. Be sure you know what's in your policy;
request and carefully review the actual contract language. If there's a
specific exclusion for "experimental treatment," look closely at the
policy to see how the plan defines such treatment and under what conditions it
might be covered. If it is not clearly defined, call the plan's customer
service line, consult their Web site, and/or write to them. Ask for specific
information about clinical trials coverage.
-
Work closely with your doctor. Talk with your doctor about the paperwork
he or she submits to your health plan. If there have been problems with
coverage in the past, you might ask your doctor or the hospital to send an
information package to the plan that includes studies supporting the
procedure's safety, benefits, and medical appropriateness. This package might
include:
-
publications from peer-reviewed literature about the proposed therapy that
demonstrate patient benefits;
-
a letter that uses the insurance contract's own language to explain why the
treatment,
screening method, or preventive measure
should be covered;
-
letters from researchers that explain the clinical trial;
-
support letters from
patient advocacy groups.
Be sure to keep your own copy of any materials that the doctor sends to your
health plan for future reference.
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If a claim is denied, read your policy to find out what steps you can follow to
make an appeal. In the book called What Cancer Survivors Need to Know about Health Insurance,
the National Coalition for Cancer Survivorship suggests that you and your doctor demonstrate to the
health plan that:
-
the therapy is not just a research study, but also a valid procedure that
benefits patients;
-
your situation is similar to that of other patients who are participating in
clinical trials as part of a covered benefit;
-
possible complications have been anticipated and can be handled effectively.
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It's never easy to deal with financial issues when you or a loved one faces
cancer. Unfortunately, costs can present a significant barrier to clinical
trials participation.
The range of insurance issues and health plan contracts makes it impossible to
deal with all of them here. You may wish to consult this partial list of
publications, organizations, and Web sites for more information:
Publications
- What Cancer Survivors Need to Know about Health Insurance
-
National Coalition for Cancer Survivorship
-
http://www. cansearch. org/
-
1010 Wayne Avenue, 5th floor
-
Silver Spring, MD 20910
- (301) 650-8868
- Cancer Treatments Your Insurance Should Cover
-
The Association of Community
Cancer Centers
-
http://www.accc-cancer.org/main2001.shtml
-
11600 Nebel Street, Suite 201
-
Rockville, MD 20852
- (301) 984-9496
- The Managed Care Answer Guide
-
Patient Advocate Foundation
-
739 Thimble Shoals Boulevard, Suite 704
-
Newport News, VA 23606
-
(757) 873-6668
-
email: ndepaf@pinn.net
-
Publications about Medicare from the Centers
for Medicare and Medicaid Services
-
New Medicare site
-
http://www.medicare.gov/
-
Medicare Helpline: 1-800-444-4606
- Facing Forward Series: Life After Cancer Treatment (features a section
on insurance issues)
-
National Cancer Institute
-
Facing Forward or by calling 1-800-4-CANCER
Assistance Programs
- Candlelighters Childhood Cancer Foundation
-
http://www.candlelighters.org
-
Ombudsman Program
-
910 Woodmont Avenue, #4607
-
Bethesda, MD 20814
-
(301) 657-8401; 1-800-366-2223 (toll-free)
-
email: info@candlelighters.org
- The Ombudsman Program helps families of
children with cancer and survivors of childhood cancer resolve a range of
problems, including insurance coverage difficulties. Local groups appoint a
Parent Advocate who works with the treatment center on behalf of families.
- Medical Care Management Corporation
-
http://www.mcman.com/
-
5272 River Road, Suite 650
-
Bethesda, MD 20816-1405
-
(301) 652-1818
-
email: mcman@mcman.com
- Working for a range of clients, including health
plans, employers, and patients, MCMC conducts independent, objective reviews of
high-technology medical care cases to assist in decision-making. While it does
charge for its services, MCMC also offers a volunteer program for those who
cannot afford to pay.
More Information Resources
- OncoLink, a service of the University of
Pennsylvania Cancer Center.
http://www.oncolink.com/
In addition to general cancer information, this Web site features a section on
financial information for patients (http://www.oncolink.com/resources/resources.cfm?c=6).
Among the topics: viatical settlements, life insurance, a glossary of financial
and medical terms, and news about billing and insurance.
- AAHP-HIAA
-
http://www.aahp.org/
-
601 Pennsylvania Avenue, NW
-
South Building, Suite 500
-
Washington, DC 20004
-
(202) 778-3200
In October 2003, the American Association of Health Plans merged with the
Health Insurance Association of America to form the AAHP-HIAA, the national
trade association representing the private sector in health care.
- American Academy of Family Physicians (AAFP)
-
http://www.aafp.org/
-
P.O. Box 11210
-
Shawnee Mission, KS 66207-1210
The AAFP's mission is to preserve and promote the science and art of family
medicine and to ensure high-quality, cost-effective health care for patients of
all ages.
- National Association of Insurance
Commissioners (NAIC)
-
http://www.naic.org/index.htm
-
2301 McGee Street
-
Suite 800
-
Kansas City, MO 64108-2662
-
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