A denial letter can make a treatment plan suddenly feel uncertain.
Your oncologist recommends a medication, procedure, scan or course of treatment. The insurance company responds that it is not medically necessary, requires another treatment first, is outside the network, or is considered experimental.
The most important thing to know at that moment is simple:
An insurance denial can be a decision to challenge, not necessarily the end of the treatment option.
Most patients have appeal rights, and cancer centers deal with authorization problems every day. Before deciding that a treatment is unaffordable or paying for it yourself, find out exactly why coverage was denied and what can still be done.
First, Find Out What Was Actually Denied
Not every insurance denial means the same thing.
A health plan might deny cancer care because prior authorization was not obtained. It may say the treatment does not meet its definition of medical necessity. A drug may not be on the plan’s formulary. The insurer may require another drug to be tried first. A physician or facility may be outside the network.
Some denials are much simpler. The claim may contain an incorrect billing code or may have been submitted without information the insurer needed.
The American Cancer Society advises patients to determine the specific reason for a denial before beginning the appeal. In some cases, a claim can be resubmitted with corrected coding, a physician’s explanation or additional medical information and resolved without proceeding through the entire appeal process.
That makes the denial letter important.
Do not rely only on what someone tells you over the phone. Get the reason in writing and keep the document.
Bring Your Oncology Team Into the Appeal
Cancer patients should not assume they have to build the medical argument themselves.
Your oncologist knows why the treatment was recommended. The physician may be able to provide the insurer with clinical records, previous treatment history, published evidence or a letter explaining why the requested care is medically necessary.
The office may also have an authorization specialist who deals directly with insurance companies.
Ask a very specific question:
“What does the insurance company need from my doctor to reconsider this?”
That is more useful than simply asking whether the office can “fight the denial.”
Sometimes an insurer needs documentation showing that another treatment was already tried. Sometimes the physician needs to explain why the insurer’s preferred alternative would not be appropriate. Sometimes the issue is authorization rather than the treatment itself.
The American Cancer Society notes that some expensive treatments, procedures, medications, hospital services and out-of-network care require prior authorization. It also warns that receiving care without required authorization can leave a patient responsible for the cost.
Whenever possible, resolve that question before beginning a treatment the insurer has not approved.
Keep an Appeal File From the Beginning
Insurance disputes can become difficult when information is scattered among emails, patient portals, bills and phone calls.
Create one place for everything related to the denial.
Keep the denial letter, Explanation of Benefits, authorization requests, physician letters, supporting medical records and copies of anything submitted to the insurer.
Also keep notes from phone calls.
Record the date, the person you spoke with, what department they work in, what they told you and any reference or case number provided. Current iPhone models even have a record call option, just make sure you announce to the rep you are recording and get permission.
Federal guidance specifically recommends keeping copies of denial documents and appeal materials as well as notes from conversations with the insurer and medical providers.
This may seem unnecessarily detailed when the problem begins.
It becomes extremely useful if the first appeal does not resolve it.
You Generally Have the Right to an Internal Appeal
If the insurer will not pay for care that you and your medical team believe should be covered, an internal appeal asks the health plan to reconsider its own decision.
Federal guidance says internal appeals can address denials involving issues such as medical necessity, out-of-network care and treatment the plan considers experimental or investigational.
The appeal should address the reason the insurer gave for saying no.
If the denial says a treatment is not medically necessary, the physician’s medical justification becomes central.
If the issue is that the treatment is experimental, evidence supporting its use for the patient’s particular diagnosis may become important.
If the problem is an out-of-network provider, the appeal may need to explain why appropriate care is not reasonably available within the network.
If the insurer requires another treatment first, the oncologist may need to explain why that treatment has already failed or would be inappropriate for this patient.
A generic appeal is less useful than one built around the actual denial.
Federal rules generally give a patient 180 days after receiving a claim denial to file an internal appeal, although patients should follow the instructions and deadlines stated by their own plan.
When Cancer Treatment Cannot Wait for a Normal Appeal
Cancer care does not always fit neatly into an insurance company’s administrative timeline.
There are situations where delaying a decision could seriously jeopardize a patient’s health or ability to recover.
Federal appeal protections account for this.
HealthCare.gov explains that patients may be able to request an expedited appeal when waiting for the standard process could seriously put their life or ability to function at risk. In urgent circumstances, an external review may sometimes proceed while the internal appeal is still underway.
The treating physician can be particularly important here because the urgency needs to be medically supported.
If treatment timing matters, ask the oncology team directly whether the situation qualifies for an expedited appeal.
Do not assume the standard appeal timeline is the only timeline available.
Get Help From the Cancer Center
Large cancer centers frequently have people whose job is to help patients navigate financial and insurance problems.
That may include a financial counselor, patient navigator, social worker, billing specialist or insurance authorization team.
Use them.
The National Cancer Institute specifically recommends speaking with hospital billing departments and notes that nurses and social workers may also help patients understand coverage, eligibility and insurance issues.
A financial navigator may also know whether the hospital has assistance programs or whether the manufacturer of a prescribed medication has a patient-assistance program.
These resources should not be treated as a last resort.
The earlier they are involved, the more options a patient may have before a large bill is created.
Depending on the health plan and state, additional help may also be available through a state Consumer Assistance Program or Department of Insurance. People covered through an employer plan may have additional resources through the U.S. Department of Labor’s Employee Benefits Security Administration.
If Insurance Still Will Not Pay, Get the Real Cash Price
There is a point at which some patients exhaust their insurance options and still want to pursue the treatment their physician recommends.
That is when the financial conversation changes.
Do not start with the billed price and assume that is what you must pay.
Ask the treatment center for the actual self-pay amount.
Ask whether there is a cash-pay discount.
Ask whether physician charges are included.
Ask what imaging, laboratory work, medications and facility fees are separate.
Ask whether financial assistance applies to the treatment.
If the treatment will occur over several months, ask whether payment is required before treatment or whether an installment arrangement is possible.
The objective is to turn an intimidating unknown number into an actual treatment budget.
Only then can you evaluate the financial resources available to you.
Before Borrowing Money, Look at What You Already Own
For a cancer patient facing a significant uncovered treatment expense, there is another question that is often overlooked:
Do you own an individual life insurance policy?
If the answer is yes, the policy may have financial value while you are living.
A viatical settlement allows a qualifying person facing a serious illness to sell an existing life insurance policy for a cash payment. The money is unrestricted, so the patient decides how it is used.
This can be particularly relevant when insurance has denied a treatment the patient still intends to pursue, or when a patient chooses care that is not covered by their health plan.
Term life insurance should not automatically be dismissed.
Although an individual term policy normally has no cash surrender value, it can potentially qualify for a viatical settlement. Cancer Care Financial’s experience also shows that qualification should not be reduced to a simple “terminal illness” label or a two-year prognosis. Cancer type, stage and the life insurance policy itself all affect whether a market exists for the policy.
Cancer Care Financial specializes in helping cancer patients evaluate this option. The company brings qualifying policies to multiple buyers so that offers can compete, and there is no upfront cost or obligation to accept an offer. Cancer Care Financial caps its commission at 10 percent.
Patients who simply want to understand whether their policy could have value can use the free viatical settlement calculator at cancercarefinancial.com/viatical-settlement-calculator without providing contact information, or speak with Cancer Care Financial at 1-844-440-7355.
A viatical settlement is not appropriate for every patient or every policy. It also should not replace an insurance appeal, hospital assistance, drug assistance or other resources that may solve the problem without selling the policy.
It is another financial option worth knowing exists before a patient takes on debt or abandons a treatment solely because of cost.
Make the Insurance Decision Before You Make the Financial Decision
When cancer treatment is denied, it is easy for the problem to become financial immediately:
“How am I going to pay for this?”
That question may come too soon.
First determine why the treatment was denied.
Find out whether the problem can be corrected or the claim resubmitted.
Bring the oncology team into the appeal.
Use the internal appeal process when appropriate.
Ask about an expedited review when treatment cannot safely wait.
If the denial continues, determine whether an independent external review is available.
Only after those avenues are understood should the remaining uncovered cost become the center of the decision.
Sometimes the insurer changes its decision.
Sometimes financial assistance closes the gap.
And sometimes the patient ultimately decides to pay for treatment outside insurance.
Whatever the outcome, the goal is the same: make the treatment decision with every available medical, insurance and financial option on the table.
People Also Ask
What should I do if insurance denies my cancer treatment?
Start by obtaining the exact reason for the denial in writing. Ask your oncology team whether the claim can be corrected or resubmitted and whether additional medical documentation could support coverage. If the issue is not resolved, review the plan’s instructions for filing an internal appeal.
Can an oncologist appeal an insurance denial for me?
Your oncology team can often participate in the appeal by providing medical records, a letter of medical necessity and evidence supporting the recommended treatment. Depending on the process, a physician or another authorized representative may also be able to act on the patient’s behalf.
Can I appeal if insurance says my cancer treatment is experimental?
Yes. Federal guidance identifies certain denials involving experimental or investigational treatment as eligible for internal appeal and, in qualifying circumstances, independent external review.
How long do I have to appeal a health insurance denial?
Federal guidance generally allows 180 days from receiving a claim denial to file an internal appeal. External review has a different deadline and generally must be requested within four months of the applicable final denial. Patients should always follow the deadlines stated in their own plan documents and denial notices.
What if my cancer treatment is urgent?
If waiting for the normal appeal process could seriously jeopardize your health or ability to regain maximum function, you may be able to request expedited review. Ask your oncologist and insurer about the urgent appeal process immediately.
What happens if my insurance appeal is denied?
Certain cases can proceed to an independent external review. Patients can also contact their state’s Consumer Assistance Program or Department of Insurance for help understanding their rights and next steps.
Can life insurance help pay for cancer treatment that insurance will not cover?
Potentially. A cancer patient who owns a qualifying individual life insurance policy may be able to sell the policy through a viatical settlement. The resulting cash is unrestricted and can be used for treatment or other needs. Individual term, whole life and universal life policies may potentially qualify.
