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Rower Michelle

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  1. Like
    Rower Michelle got a reaction from PaulaC for a blog entry, Managing Health Insurance Mayhem   
    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. 
     
  2. Like
    Rower Michelle reacted to LCSC Blog for a blog entry, "Come on down!"   
    Except I was not sitting in the audience for "The Price Is Right" when I heard my name called. Nor was I needing to guess the cost of my infusion with my treatment that day contingent on my guess not exceeding the "actual retail price." And neither were there any of "Barker's Beauties" to wave their hands and showcase what items I would be attempting to price right. No. There were only multiple oncology nurses standing in front of the Infusion Center's entry door calling out the names of the next patients lucky enough to begin their treatment. It wasn't exactly "Plinko," but once inside the Center, the fun, such as it is, really begins.
    At least that's the way the activity appeared to me. The preceding day was July 4th so the Center was closed forcing those Thursday patients to be rescheduled to either Wednesday or Friday. As a result, the waiting area was particularly full with patients, along with their family and friends, all of whom are encouraged to attend. In the midst of this crowd, I sat and waited. We hadn't exactly been assigned numbers, but we were assigned oncology nurses and therefore could only enter the Infusion Center with their assistance.
    Then, while all of us "waiters" looking at the entry door waiting for an oncology nurse to walk through and call our name, the door lock clicked open and out walked two oncology nurses. As soon as they cleared the door and entered the waiting area, they called out their respective patient's names (unfortunately not mine). Upon hearing their names, the two patients and nearly half a dozen of their supporters got up and moved eagerly toward the entry door. It reminded me of the beginning of "The Price Is Right" when three audience members' names are called in quick succession and implored to "Come On Down!" by George Gray (Johnny Olson, the original announcer, retired years ago) and officially become one of that day's contestants.
    However, once inside the Infusion Center, It's dead serious. Your life is at stake, maybe even at risk, depending upon your cancer/treatment, and at this point, you're not playing any more games (although occasionally, you may be guessing the price of things and wondering how it all gets calculated). So you slide into your Barcalounger, hold out your arm to have your barcoded wrist ban scanned and prepare for your hopefully, life-saving infusion, and don't smoke 'em, even if you got 'em.
    It's rare that you'll see your oncologist in the Center. Typically, they'll be seeing patients in examining rooms, performing surgery or rounding in local hospitals. But they're always a phone call away should the nurses need any additional instructions or clarification. Generally speaking, once inside the Center, all goes as anticipated for us patients: you're in, you're treated, you're out. And when you're out, new patients names are called and on and on it goes, just like "The Price Is Right," except the program doesn't end in an hour. And just like "The Price Is Right," where there are no shortage of audience members wanting to participate, at the Infusion Center, likewise, there seems not to be a shortage of patients wanting to be treated either. (Granted. it's not exactly the same thing, but you get my drift, I'm sure.)
    Cancer is not fun, nor funny, and an Infusion Center is not filled with anticipation of cash awards and magnificent trips. There is however, lots of empathy and understanding - from your support system and from staff as well. But it's the last place you want to be, unlike "The Price Is Right."
     
  3. Like
    Rower Michelle got a reaction from BridgetO for a blog entry, Managing Health Insurance Mayhem   
    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. 
     
  4. Like
    Rower Michelle got a reaction from Tom Galli for a blog entry, Managing Health Insurance Mayhem   
    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. 
     
  5. Like
    Rower Michelle reacted to Susan Cornett for a blog entry, Taking a page from Tom's book   
    Today I celebrate three years of survival! I am so happy to have found this community of people.  You all make this journey so much better.

  6. Like
    Rower Michelle reacted to Tom Galli for a blog entry, A Picture is Worth 15 Years   
    I'm the guy who paints a toenail for every year I live beyond my February 4, 2004 diagnosis day.  This year our toes are LUNGevity Blue to honor the foundation that is dedicated to changing outcomes for people with lung cancer through research, education and support.
    There are many people who've been instrumental in my survival and making a life after; none are more important than my loving wife -- Martha Galli. If I can live, so can you!
    Stay the course.
    Tom Galli
  7. Thanks
    Rower Michelle reacted to Tom Galli for a blog entry, Free and Invaluable   
    Using the words free and invaluable to characterize lung cancer medical care is a hard sell. I’ve seen so many scams promising this, that, and the other thing that deliver nothing more than a money pit.  So I was indeed skeptical when Dr. David S. Schrump introduced his National Cancer Institute Intramural cancer treatment program, at our April 2018 LUNGevity Summit, with the words “no cost to patients, including travel and lodging.”
    Why didn’t I know about this resource?  I’ve encountered so many newly diagnosed folks who had no or inadequate insurance and who had to forgo treatment because of financial concerns. Yet, there is a sophisticated, taxpayer funded, medical system that designs “unique to patient” protocols including surgery, radiation, chemotherapy, and newly emerging treatments. And, it is free! All patients at the NIH are on investigational protocols, including those who are receiving standard care, so that their tumor tissues, blood, etc can be used to develop new cancer therapies. Once a patient is enrolled onto a protocol, care is provided at no cost. There is no third party billing, deductables, etc.
    Then on the second summit day, I learned Dr. Schrump’s Surgical Oncology Team is developing unique vaccine-like immunotherapies using tumor material surgically removed from a patient — a tailored and individualized immunotherapy agent. In an ongoing vaccine study, Dr. Schrump’s team observed immune responses to lung cancer-associated proteins in 60% of patients; several responders have had unusually prolonged disease free-survivals, supporting further evaluation of the vaccine. Dr. Schrump hopes that personalized vaccines may one day be an alternative to adjuvant or post-surgical chemotherapy, the current standard of care. Much more work needs to be done to determine to feasibility and potential efficacy of this approach.
    Moreover, they are using aerosol delivery methods as alternatives to IV or oral administered drugs to increase the uptake of drugs into lung cancer cells, and “prime” them for attack by the immune system. Indeed, his presentation was filled with very innovative methods of attacking lung cancer with promising results.
    If you are an American and don’t have the financial resources for lung cancer treatment or if your medical team has run out of treatment ideas, contact the National Cancer Institute.  You don’t need a physician referral. Email [email protected], introduce yourself and your diagnosis stage and type and put your phone number in the email.  Free and invaluable may indeed be words appropriate to use in concert with lung cancer treatment.
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