Insurance companies are denying coverage for proton therapy treatment that could save the lives of cancer patients. The current state benefit plan covers proton therapy for only 5 percent of cancer patients because the state relies on the recommendations of a third-party vendor hired by insurance companies, who have a vested interest in limiting coverage and payments rather than providing the best possible care, according to a statement from the Tennessee Cancer Patient Coalition. The length of time the health insurer has to review an appeal – typically health insurers use the full 30 to 60 days they are allowed. My doctor explained that the insurance company was using outdated information from 2014 that had since been updated. Tag: does insurance cover proton therapy? Include any emotional or non-medical issues that may develop from other types of treatment. The largest insurance network is Blue Cross and Blue Shield. ARLINGTON, Va., July 12, 2017. While it is true that there may be a few insurance companies that do not cover proton, with the BOB support group help, most finally come around. He is 100-percent confident of the cancer treatment he received at ProCure Proton Therapy Center in Oklahoma City, he said. Health insurers will also take the denial appeal more seriously once an attorney has been hired. Private insurance companies generally cover proton therapy on a case-by-case basis, depending on the type of tumor, previous treatments, medical history and other factors. The proton therapy group may also have included more patients from “privileged backgrounds,” Drs. Does health insurance cover proton beam therapy? 6. The bill would have allowed the State of Tennessee Insurance Plan to cover hypo-fractionated proton therapy for members of the state health … As someone else has noted, the ProtonBob website … It is true that Kaiser will not cover proton - those men who are 65 usually drop Kaiser, go to Medicare and use AARP as their supplemental. Treatment-based coverage. The plaintiff in the case says the company denied his request for pre-authorization for the treatment because it fell under an exclusion in his plan titled “Experimental or Investigational or Unproven Services” and therefore was … It passed without objection in the House Insurance … Obtaining Health Insurance Coverage for Proton Treatment. While this information should exist in the health plan’s computer system, unnecessary delays can be avoided by having a copy of the approval letter ready to provide upon request. Fortunately, our proton therapy center members partner with cancer patients to face this challenge by taking a proactive approach to appealing these denials. Once the steps above have been completed, cancer patients can write a professional letter to formally request an appeal of the coverage denial. At this stage of cancer, proton therapy offers a better than 90-percent chance of cure at 10 years. However, those who were already receiving the treatment would continued to be covered, she said. The patient can request this information for the insurance company and the health insurer is legally obligated to provide it. What is it … In a high-profile case, Doug Terry represented Ron Cunningham, whose wife’s insurance company, Aetna, denied coverage for proton beam therapy to treat stage IV nasopharyngeal cancer.Ron and his wife, Orrana, were forced to borrow money against their dream house to cover the $92,082.19 cost of proton beam therapy. House Bill 1515, by Rep. Marian Cooksey, would prohibit health benefit plans from subjecting proton radiation therapy to a higher standard of evidence than other radiation therapy when making coverage decisions. Our patient access specialists can work with your insurance carrier to define your benefits. Aetna Life Insurance Co. fails to cover proton beam therapy for treating cancer by incorrectly characterizing it as experimental and investigational, according to a proposed class action filed in the Southern District of Florida. This guide provides various tips and strategies to help cancer patients strengthen their case. Two major insurance companies have announced that they no will longer pick up the tab for proton-beam therapy to treat early-stage prostate cancer. What is it … Keep a record of every phone call made and received. The American Society for Radiation Oncology (ASTRO) has issued an update to its recommendations for medical insurance coverage regarding the use of proton beam therapy to treat cancer. These charged particles damage the DNA of cells, ultimately killing them by stopping their reproduction and thereby eliminating the tumor. Contact the local State Representative or Senator who may have influence with some insurance companies. Mclean, VA 22106. If it is discovered that this is not the case, this will need to be appealed as well. Does insurance cover proton therapy? Doug Terry Knows Proton Beam Therapy Insurance Denials. Receiving an approval for a consultation with a proton therapy physician does indicate that proton therapy treatment is approved. Insurance companies rely on the fact that many members cannot, will not or are unable to fight them when they deny claims. As an outpatient, you pay a Copayment, and the Part B deductible applies. The above coverage of Key Cover, Flood Allowance & Policyholder Personal Accident claims will not affect your No Claim Discount (NCD). Proton beam radiation therapy (PBRT) is intended to deliver higher, more targeted radiation with less damage to collateral healthy tissue than external beam radiation therapy (EBRT) using photons (x-rays) when used to treat solid tumors. If treatments are being administered in an inpatient setting, such as a hospital, the treatments will be covered by Medicare … Proton Therapy was approved by the FDA in 1988 and most cancer diagnoses have been covered by Medicare since 1997. Document the conversation including questions asked and answers received. In many cases, patients covered by Medicare supplemental insurance often incur few net-out-of-pocket expenses for treatment after deductibles, copays/coinsurance, and annual maximum payments are met. How many levels of appeals the health insurance plan allows – this is usually found in the health insurer’s benefits handbook or what is called often called the Summary Plan Description. While most medical insurers will consider proton treatment on a case-by-case basis, our financial coordinators will provide further assistance in coordinating these sensitive financial matters. While it is true that there may be a few insurance companies that do not cover proton, with the BOB support group help, most finally come around. The largest insurance companies, in order, are Unitedhealth Group, Wellpoint, Kaiser Foundation Group, Aetna, and Humana. For thousands of cancer patients, access to insurance coverage for proton therapy is a matter of life and death. The most advanced delivery method of proton therapy is actively scanned pencil-beam proton therapy. In other words, the proton beam facilities seek to treat more common cancers. This is often referred to as a. Proton therapy is an FDA approved, reliable form of cancer treatment. As of Jan. 1, a handful of insurance companies removed proton therapy from their insurance coverage options, state Rep. Marian Cooksey said. Written input from a physician can be a valuable resource when appealing a denial. His attorney said the disease is … Coverage varies by insurance company and disease type. The updated Proton Beam Therapy Model Policy provides guidance to payers on clinical … Doug Terry Knows Proton Beam Therapy Insurance Denials. We encourage all patients, healthcare providers and other interested parties to take part in this important initiative by sharing their proton therapy treatment stories or their experiences – and challenges – gaining access to this quality cancer care treatment. During conversations with the health insurer, remain calm and respectful even if frustrated with the representative on the call. “It was the best chance for me,” Bridwell said. It is possible in this situation that the health insurer has changed their coverage policy since the legal case was determined. Medicare generally covers proton beam therapy. The move came in response to proposed legislation that would have barred insurers from holding proton therapy to a higher standard than that of conventional radiation treatment for cancer. These conditions may help overcome a. Keep a copy of the appeal approval letter. Click here to see the original article on the Edmund Sun website. The steps required to file an appeal – these actions must be followed exactly in order to overturn a denial. We surveyed 108 national insurers and radiation oncology benefit management companies to find out how they make decisions – and 103 opted not to share any information. The type of health insurance plan they are participating in (HMO, PPO, High-Deductible, HRA, Indemnity, Medicare or Medicare Supplement). Learning a health insurance plan has denied coverage for the treatment plan a cancer patient and their physician have determined is most appropriate for them is a challenge most never expect to face. Valuable information can be gathered from various cancer advocacy groups and organizations, books, and respected internet websites. Proton therapy is a type of external beam radiotherapy that uses ionizing radiation.In proton therapy, medical personnel use a particle accelerator to target a tumor with a beam of protons. ProCure does a great job in helping the patient navigate through therapy, Bridwell said. The reason the coverage was denied by the health insurer – this should be provided in writing. Founded in 1990, the NAPT advocates to ensure patient choice and access to affordable proton therapy and to encourage cooperative research and innovation to advance the appropriate and cost-effective utilization of proton therapy. Proton therapy is like a laser beam that goes to the tumor without destroying healthy tissue and organs. Each of these payers will make an individual determination on what types of cancer they will pay to have treated with proton therapy. If a representative believes someone is abusive on the call, they have the right to terminate the call. The bill would require some private insurance companies to cover proton therapy treatments for most types of cancer. In a case involving proton therapy, some California insurance companies have historically had some leeway in deciding what types of procedures to cover. Additional beneficial information cancer patients should try to obtain. Our patient access specialists can work with your insurance carrier to define your benefits. Navigating the appeals process can be both daunting and frustrating for cancer patients and their families. Maintain copies of any written communication sent to the health insurer, healthcare provider, or physician as well as any written documentation received. Mayo Clinic specialists work with each patient and the health insurance company to determine if proton beam therapy is covered, if that is the recommended treatment. Cancer patients uncomfortable with the appeals process sometimes seek the legal services of an attorney. Feb 01, 2016 at 6:15 PM RICHMOND — A state panel will look at how insurance companies cover proton radiation therapy, the type of treatment now done in … Bridwell said the benefit to insurance companies is that the residual side-effects resulting from proton therapy are minimal. House Bill 1515, by Rep. Marian Cooksey, would prohibit health benefit plans from subjecting proton radiation therapy to a higher standard of evidence than other radiation therapy when making coverage decisions. Provision Cares, a Proton therapy group in Knoxville, has provided such therapy to more than 3,000 patients so far and will celebrate six years of being in business on January 20, 2020. Proton therapy was approved by the Food and Drug Administration in 1988 but can be unavailable to many cancer patients if their insurance company does not cover it. While most medical insurers will consider proton treatment on a case-by-case basis, our financial coordinators will provide further assistance in coordinating these sensitive financial matters. Cancer patients can also advocate on their own behalf to overturn these denials. Just recently BlueCross/BlueShield of Texas, NewMexico,Oklahoma & Illinois were going to drop proton as a coverage. So they’re trying to hold them to a higher standard than what they are with traditional radiation. They learned that proton therapy results in fewer residual effects from the treatment. All company-registered vehicles must have all their drivers insured. Original Medicare covers most medically necessary radiation therapies used by patients who have been diagnosed with cancer. We stressed to the board members that proton therapy is FDA-cleared and covered by Medicare as an effective cancer treatment. Their first response is often to contact their health insurance plan immediately upon receiving the denial which is not recommended. Make sure the patient does their homework and knows what treatments are available, said Bridwell, owner of Ditch Witch of Oklahoma and Arkansas. Please note that before starting the appeal process, speak with the financial counselor or billing office representative of the treatment facility selected so they can further explain the process and offer support. “I have no side effects, no issues that they’ve had to treat.”. Each additional driver cost of RM10 will be waived by Proton Insurance Program (PIP) All Driver coverage. Proton therapy is a newer form of radiation therapy that may be more expensive than traditional radiation therapy with X-rays. Proton therapy is an alternative form of radiotherapy, which is conventionally delivered using X-rays. Cooksey is the author of House Bill 1515, which would prohibit health benefit plans from subjecting proton radiation therapy to a higher standard of evidence than other radiation therapy when making coverage decisions, she said. If a patient receives an approval for their treatment after an appeal, make sure that the costs are covered at the rate described in their plan. A routine blood test for an insurance policy alerted Bridwell that he had prostate cancer in 2011. If information identified by a cancer patient or their family includes medical terminology they do not understand or the relevance of to their diagnosis and treatment, please discuss with a member of the medical team at the proton therapy facility selected. If the representative is not helpful or responsive on the call, request to speak to a supervisor or manager. When writing an appeal letter all items required by the health insurer’s appeal process must be included with supporting documentation. Receiving a cancer diagnosis is difficult and can be very frightening. For instance, patients who received proton therapy were, on average, older (likely because Medicare typically covers the cost of proton therapy) and had more health issues. Insurers cover proton therapy for children's cancer, and for cancers in the eyes and spine because the radiation oncology association has for several years said … Once communication with the health insurer begins it is extremely important to document every interaction. Continue to follow-up with the health insurer through all levels of appeal even if continued denials are received. Assure that all steps in the appeals process are not bypassed. Proton therapy is covered in the United States by Medicare and many insurance providers. Radiation Oncology Alternative Payment Model, Website Design and Development by VIEO Design. A proton beam can deposit its cargo into a tumor and stop. Medicare Part B (Medical Insurance) covers this therapy for outpatients or patients in freestanding clinics. Avoid verbal appeals as they do not provide new information to the health insurer. MD Anderson Proton Therapy Center accepts several major insurance plans as well as Medicare and Medicaid. Any available legal cases that are similar to the cancer patient’s situation. Texas Center for Proton Therapy participates in most health insurance plans, Medicare, Medicaid, and selected Health Insurance Marketplace plans. In contrast, X-rays are unstoppable, and barrel through the body, affecting every tissue in their path and continuing to deliver radiation as it leaves the body. Cancer patients have the right to ask for the rationale used by the health insurer to determine a denial of coverage. Does insurance cover proton therapy? “The only thing that my insurance company has paid for since my treatment is office calls,” Bridwell said. When walking through this sometimes lengthy process, keep in mind that winning an appeal takes patience, persistence and a good understanding of why proton therapy is a viable treatment option. Our financial coordinators can assist you in working with your insurance company to obtain authorization. Copyright © 2021 NAPT All Rights Reserved. Physicians at the proton therapy facility selected can help provide important medical documentation. Cancer patients should know the following; In addition to identifying the facts and seeking support before contacting the health insurer, it is just as important for cancer patients to perform their own medical research to support their appeal. 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