Second Opinions, HMO's and Insurance

unclaw2002

All,

It was suggested that I should post my reply to a previous post as a separate discussion topic. While many of us fight this horrible disease with everything we possess sometimes we are forced to battle on a different front at the same time in order to get our loved ones the best medical care possible.

While the medical community and those of us on this site all urge everyone to get a second opinion and to go to a cancer center designated by the NIH or other medical professionals as a cancer center that specializes in the treatment of EC, to gain access to the most up to date treatment, clinical trials and expertise --- it is important to understand that sometimes difficulties arise in trying to achieve that. One of the areas that creates problems is medical insurance and finances, the type or lack thereof and what needs to be done to get treatment especially when you are away from home.

It is important to really understand the patient's insurance policy, the clauses, second opinion requirements, appeal options etc. (believe me reading them is like greek - and they are not meant to be understood - understand??? It is also important to speak to the treating physicians and find out and get a committment of what they are willing to do for you if you run into a roadblock because the insurance is denying treatment --- this is where it is critical for you to have facts and backup information to go to battle with the insurance company. If you get into a life or death battle you should come to this site for help and support, but you should go to the insurance commissioner/regulator in your state to request assistance. As a first step you should be able to find out what experiences the Insurance commissioner has had with the insurer you are having problems with and perhaps they can assist in suggesting approaches or even intervening on your behalf.

If finances, or housing become issues there are organizations that can help with housing. There is help out there. Perhaps we could even organize a project with some of the folks on this site to try and put together a list and web sites from some of these organizations. I know a group of us worked together to get April declared Esophageal Cancer Awarness Month in our States --- and we should probably start that effort once again this fall I think there is such a wealth of knowledge on this site among us. Let me know if you are up for it and perhaps we can organize something for the group --- even post a link on some of the EC web sites. In any event I was working late and couldn't get to sleep but I need to try now because tomorrow comes early:)

Sometimes it seems as if it isn't bad enough we have to fight the cancer, but then we have to deal with all the insurance stuff, the hospital mishaps and just stuff. When I get the most discouraged I try to focus on how I can help my dad, and others, and be a small force to raise awareness about EC, get more research dollars, and keep on spreading the word that EC isn't always a death sentence and yes there are survivors and more and more every day.

Previous Post below to questions
about problems with Kaiser in California - especially relevent to folks eligible for Medicare . . .

Jim,

I must caution you about HMO medical insurance for seniors and how they refuse to provide second opinions or medical services out of network unless you create huge waves. My father was 78 and instead of being on medicare with his military TRICARE for life supplemental insurance he was talked into signing up for a Humana Gold Plan --- because it gave him a health club membership at no cost and he thought that was a great idea.

If he had had Medicare he would have had no insurance problems for the most part. With Humana they refused to allow him to get a second opinion at a major cancer center, not merely refusing to allow him a second opinion at an esophageal cancer center. They offered him a second opinion at a local hospital down the road. Absolutely absurb. My dad's primary care physican and even his oncologist ordered the second opinion at Sloan in NY --- and my dad traveled at his own expense and saw the doctors. I must say the second opinion from Sloan entirely changed my dad's treatment plan and may have saved his life.

Even with the efforts of his doctors and the information about how valuable the second opinion was and how essential it was to his care because of the rare cancer and my efforts and information as well, Humana refused to allow the second opinion at Sloan and refused to pay for it. We were fortunate that Sloan reduced some of the charges and that our family has the financial resources to pay for this second opinion. But it didn't stop there.

Given the treatment of my dad by humana, the advice of some medical professionals and others, the family decided that it would be better to be on Medicare, I was able to cancel the Humana health insurance policy and get my dad on Medicare so that he doesn't have to deal with the horrible HMO process. You may have some problems because there may be enrollment issues and open window dates (we were lucky we were within the official cancellation timeframe). But in talking to the Insurance Commissioner of my State and the Medicare folks I am certain that if Humana had refused to allow him to change his policy to Medicare that we would have been able to get it down even if it took a few extra months.

I might add that I also think that his cancer could have been diagnosed earlier as well - he went in over a year and a half before his final diagonosis complaining of swallowing and digestive problems --- but was ignored. In fact they even put a camera in his stomach to do a stomach emptying test and didn't check his esophagus - unbelievable. Just kept telling him he wasn't chewing his food properly.

Good luck. And if you have any questions don't hestitate to ask or send me an email on this site or at collinscin@gmail.com

Best,
Cindy

Unknown

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Tina Blondek

Thanks for posting
Cindy and William,
Thank you both for posting such wonderful, helpful information. Especially for senior citizens with this ec disease! The insurance and medicare and supplemental insurance is all most confusing! Thanks again and the best to both of you!
Tina

g041579

unknown said:

This comment has been removed by the Moderator

The Balanced Budget Act of
The Balanced Budget Act of 1997, (Pub.L. 105-33, 111 Stat. 251), was signed into law on August 5, 1997. It was an omnibus legislative package enacted using the budget reconciliation process and designed to balance the federal budget by 2002. Among many other things, the Act contained major Medicare reforms. Aimed to reduce Medicare spending, it reduced payments to providers such as hospitals and nurse practitioners. However, those payments were raised in subsequent legislation in 1999 and 2000.

This was passed by the republican congress in 1997.It's their attempt to privatize
Medicare.Being in the northwest,I've spoken to Canadians and have yet to find one
that didn't like their health plan.Profiteering off illness is wrong , Jesus was about helping the poor and down trodden not the bottom line.
William, I've learned a lot from your posts about EC and appreciate them
dearly. Phil