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dealing with insurance companies

daisy366's picture
daisy366
Posts: 1493
Joined: Mar 2009

I can relate to the problems with insurance. I spent many hours on the phone trying to get the PET scan my doctor ordered. I learned a few things that might help you:

1. They have the standard protocols that they will not compromise. Go with the flow and have the tests they WILL cover first. This can be frustrating and a waste of money but they won't budge with it - I learned.
2. they have internal advocates that can help - request a CASE MANAGER. This person helped me by advocating WITHIN the system. Get to know this person and ask them how you can get what you need.
3. PERSIST. I read that after a procedure is denied, that most insurances finally give in with persistence. Follow the appeal process and keep appealing - DON'T QUIT!!!!
4. become educated. Use their system to your advantage. I researched the insurance company's own criteria for PET scans and used this in my argument for it.
5. enlist the help from your doctor. They know how to use the system and sometimes they will order the same test another way. Tell your Dr. of your problem and ask help.
6. Keep good records.
7. Try to stay calm during this. They are bureaucracies and go VERY slowly. Accepting and expecting this will lower your stress and anxiety.
8. If all else fails - A colleague of mine used this one, not me. Essentially it's a statement to them that if you die because of their failure to provide the ordered test, your heirs will sue them!! It worked for her!

Yes, I finally got my PET scan. And you will get your tests too. Unfortunately, I will probably have to repeat this next time a PET is ordered.

Hang tough, Ladies. Mary Ann

Songflower's picture
Songflower
Posts: 632
Joined: Apr 2009

What insurance do you have?

Diane

daisy366's picture
daisy366
Posts: 1493
Joined: Mar 2009

I think these suggestions hold true for any company. I know someone who had trouble with medicare - getting approval for chemo drug. Took some advocacy. We just can't give up because they are hoping we do. When I was successful the PET scan scheduler congratulated me - said most patients don't keep up the fight and never get what they wanted.

weezey610's picture
weezey610
Posts: 1
Joined: Apr 2010

I have uterine cancer that went into my colon. I now have a colostomy. I finished two rounds of chemo and one round of radiation. Kaiser my previous insurance covered pet scan - no issues. I had before and after pet scans and I had to switch because my company is going to one insurance company - Aetna. Aetna is denying my petscan because of a bulletin saying that petscans are considered experimental in staging and diagnosing uterine cancer.
Pet scans glow if there are any cancer cells hiding. CT scan will just tell me the size of the tumor. I have been fighting for a week. I'm going to contact them and tell them theyw ill be sued if I dont get covered.
I was first diagnosed in 2000. I was only given 2 years of followup and never told it could come back. I was told we got all of it. Well it came back - I found it through a colonscopy.
Any ideas how to rip through the appeal process.

TiggersDoBounce's picture
TiggersDoBounce
Posts: 413
Joined: Oct 2009

I have no idea how to fight the fight, but I am sure someone on this board has been there and back and will help you :)

Wishing you the best in your treatments....keep fighting!!

Laurie

jazzy1's picture
jazzy1
Posts: 1387
Joined: Mar 2010

I've got uterine cancer too and was always wondering why the PET scans weren't used. Apparently another person with this cancer found out that the TEST ALWAYS GIVEN THE OKAY WITH UTERINE IS CAT SCAN. All others are not approved and if you go with the CAT-scan and then find something they generally will pay for next higher level scan such as PET. This happened in my case as the CAT found something on my liver and doc had me setup for PET...yep the insurance did pay now. As Mary Ann mentioned above, must go with the steps and have to do cat and then find something go with PET.

I'll tell you what I've learned in life about getting what you want...FIGHT AND DON'T GIVE UP. In your case when dealing with insurance company can you find a CASE MANAGER. I had one and she was helpful but didn't have approval of tests dealing with, but bet they can help or guide. Keep moving up the ladder at the insurance company and don't give up. You'll find the right person. Do you have a billing contact at your docs office who can help? My oncolo has a wonderful billng coordinator and she has 30 yrs experience in the medical industry. She has given me lots and lots of help.

Best to you
Jan

Northwoodsgirl
Posts: 201
Joined: Oct 2009

There is a undertaking within the health insurance industry to decrease the utilization and therefore costs of all imaging...for cancer and every other indication. If you look at how imaging procedures have increased over the last 10 years it is a hugh expense for the insurance companies...thus all of the restrictions.
They will cover cheaper CT scans which give off radiation vs. MRIs which don't give off radiation. So keep pushing for the test your physician requests (based on medical evidence of course:))

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