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Managing Health Insurance Mayhem

Rower Michelle


Blog Entry is the Teamwork of both Michelle and Tom Gali:   

After receiving a lung cancer diagnosis, the last issue, one would expect is problems with health insurance.    While it’s unusual to have a claim fully denied, delays that effect diagnostics or treatment are quite common. Here are my 10 tips for dealing with health insurance problems.


1. Get your companies Human Resources staff engaged. Find out who has responsibility for claim payment. If it’s the employer, then they are self-insured and typically have an insurance advocate to fight the battles on your behalf. Get them in the fight. If the health insurance company pays the claim, expect difficulty in authorization and payment. Read your policy about appeals. Every determination that denies or limits care can be appealed.  For example, it’s possible to have a non-network provider paid at the in-network rates for a specialty physician.  Be assertive, do not take the first “no”. Appeal, appeal and appeal again! 

2. Realize each state has an office that regulates insurance. Find out their email address and provide copies of each claim to the office for “information and action as appropriate.” If you need them to act, they will have a ready record of your case on file.

3. Schedule a face to facemeeting with cancer provider’s financial team.Understand how they process insurance claim submittals. Who does what to whom and who is in charge. Get names, phone numbers and email addresses for key people in the claims department. Sometimes providers have a nurse who manages pre-certification requests. Get to know this nurse. Call or email this nurse first if insurance does not pre-approve a diagnostic or procedure. Insurance companies have definitive rules about receiving medical records. Sometimes the lack of a record becomes the log-jam.  

4. Get to know the healthcare provider’s patient advocate.It’s important to establish a relationship with this office.  They know how to work the health system bureaucracy. 

5.Don’t accept “I’m waiting for a call back” as an answer.You will need to be assertive as the squeaky wheel gets the grease. Use a “five-why” response technique. Ask “why” the wait, then follow with another “why” question and another and so on. Provider or insurance company bureaucracy is their problem, not yours. You are paying for it to work efficiently. When it does not, they owe you and answer as to why not.

6. Do not sign any documents at the health system requesting foran “advance or estimated payment” until the insurance issues have been sorted out. Lung cancer treatment is expensive, you do not want to be on the financial hook for treatment that the insurance company is supposed to pay for as part of the benefit design.  Sometimes there is a “step therapy” or pharmacy formulary requiring a treatment regimen be tried first.  Step therapy can also be appealed through a “peer to peer” conversation with your doctor. 

7. Create a log and document everything. When discussing your claim with an insurance company record everything. Record the claim number, date of service, date of claim, time of your telephone conversation and first and last name of each person you speak with. You may not actually be speaking to a member of the insurance company, but one of their “specialty care” vendors.  It’s important to know who all the players are. Sometimes vendors do not follow the insurance company rules.  

8. Ask the insurance company to assign a medical case manager. This is typically a nurse that can help navigate the health insurance system.  Insurance companies often have free phone resources for cancer patients such as mental health counselors, dietitians and physical therapists.  Find out what services are available since they are not typically advertised in benefit brochures.  

9. Pay attention to your mail. You’ll soon receive a deluge of Explanation of Benefits (EOB) forms; they are all different and are confusing.  Put someone in charge managing your EOBs. Create a log recording the date of treatment, the provider, the claim number, amount paid and amount denied. Read and understand the numeric codes explaining reasons for payment or denial. Sometimes, insurance will issue a “partial benefit” payment or apply financial penalties.  This information is usually buried on the EOB.    Do not pay any provider bills until the EOB has been received.  Hospital billing errors are frequent. 

10.  Stay calm. Every problem has a solution. When discussing your problem and you get a techno-speak response, ask for a plain English explanation. Be ready to interrupt   (it’s not rude if you don’t understand!) Save your energy for getting well. 



Recommended Comments

Thank you, Michelle, for taking the time to compile this.  One never knows when it might be needed.  Insurance companies are not fun to deal with and are "sticklers" when it comes to details.   So far, I thank my lucky stars that I have not yet had to do battle with them yet, but I am very new in this "game."   Thanks again!!

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Thank you to those who took the time to create this helpful resource for all of us! It is clear, organized, well written and invaluable. It also makes me realize that I need to start documenting and paying way more attention as I've had numerous scans, surgery/hospitalization and there is a high probability there will be more to come.

I have one question I'm not sure you can answer. My husband will be retiring soon and we will lose our private insurance plan that is liberal in its coverage. We will both go on medicare when this occurs. I am looking at supplemental plans and want to choose the best one in terms of coverage for pre-existing medical conditions and catastrophic illness coverage. What is the best way to approach finding the best plan? Are there any resources, companies, providers, etc. that can help us make this critical decision? I would be grateful for any advice on this front.

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Hi Jane, 

You sure did hit the nail on the head.  The commercial coverage plans are more comprehensive than Medicare.  I'll be in the same situation after my COBRA runs out.  Ironically, the coverage standards spelled out in the Affordable Care Act, do not apply to the Federal programs.  

  If you travel or seek care out of state, then you will need the Fee for Service traditional Medicare with parts A, B & D, then you will need a supplemental to cover the copays.  If you don't mind working with in network benefits then the other option is to look at Medicare Advantage Plans.  

I have a few ideas on how to sort through the plan selection:  you could call the American Cancer Society Help Line, Cancer Recovery Foundation, Gilda's Club's Cancer Community Support Line  or  AARP is likely to be a resource too.  Worth a shot?   https://www.cancer.net/navigating-cancer-care/financial-considerations/financial-resources   

Our financial advisors have a Medicare broker on staff to help make selections as well.   The cancer clinic social worker might have some ideas as well.  Let us know what you find out, it will help a lot of us.  


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