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Bone Marrow/Stem Cell Transplant Frequently Asked Questions
9. Will my insurance cover the transplant?
Check your insurance coverage early. The transplant center will start the insurance approval process by sending your health insurer a letter requesting pre-approval of your treatment. The insurance company may request a complete history of your physical condition, a copy of the treatment protocol, the hospital's informed consent document, your laboratory and x-ray results, and your physician's recorded treatment recommendation. Make certain that these materials are sent out promptly, if requested.
Get a copy of your insurance policy if you don't have one. If you are insured through work, your employer is required to provide you with a copy of your policy. Review it carefully to determine what is covered and what is excluded. If you are uncertain about your coverage, ask your medical provider or insurance representative to explain it. You will want to determine if donor searches and cost for collection of cells are covered. Sometimes it is not specifically stated in a policy. Clinical trials may or may not be covered by insurance. It is important to check with the insurance company prior to entering a clinical trial.
If your insurance company rejects coverage of the bone marrow/stem cell transplant, ask for a written explanation and find out how to appeal this denial. Whether there is an appeal process or not, ask your doctor or hospital to formally request coverage again. Many times, an insurer will reverse its position, especially if there is a second reviewer or if you are undergoing this treatment as part of an approved clinical trial. Be sure to comply with the time requirements. Ask for the appeal in writing and send it certified mail, with return receipt requested. See if your doctor will supply medical information that supports the treatment and include it with the appeal.
If there is notice of an appeal, and you cannot get a quick reversal, continue to follow the appeal process. At this point, your doctor and transplant center should also be providing the insurer with scientific support information and include a listing of other institutions now providing this procedure. Be persistent. The "paper trail" between your transplant center and your health insurer may become very important if coverage is denied. Organize your own paper trail file.
If your health insurance is paid through your employer, ask if they can and will make efforts to help. Sometimes the employer may pay for treatment rather than work with the insurer. At other times, the employer can put pressure on the insurer, particularly if the employer spends a lot on health benefit coverage.
At some point, it may be advisable to consult an attorney. The attorney will require information to determine if the insurer is discriminating in its policies. It is possible in some areas that laws protecting disabled persons may apply. The definition of who is disabled or handicapped could cover the patient in some cases. Should you require the help of an attorney, consult one who specializes in insurance denials.
Individuals at insurance companies generally want to assist you. Case managers, for example, can be very helpful to patients. Often medical directors, who are physicians, make the decisions about what would be the best care. Approaching them as people who want to help is the best way to begin.
There are also government agencies at the federal level, such as the Equal Employment Opportunity Commission, and at the state level, such as the Commission on Human Rights, which are designed to help the average citizen. These agencies are "user-friendly," which means that you can personally go to the agency and speak to an investigator about your problem. Sometimes they might even be willing to file suit for you.
Medicare and Medicaid
If you are a Medicare or Medicaid patient, contact the treatment center's social worker or patient financial services to discuss your options. They will work with you to understand what coverage is offered. If you are rejected coverage, ask to be informed of your appeal rights. You have the right to appeal the denial of a service that is medically necessary. If you have Medicare, make sure the transplant is conducted in a Medicare-friendly facility. Call 800-MEDICARE if you have questions about your coverage, or contact the Medicare Rights Center. (See Resource Listing)
Navigating health insurance can be a complex process, and you will likely have specific questions about your coverage. If your questions are outside the scope of your treatment center, or if you are not getting the answers you need from your insurance company, please refer to the resources listed under Financial and Fundraising, Insurance and Prescriptions, and Legal Rights and Workplace Issues in the Resource Listing. It is also helpful to consult with a social worker to provide guidance on navigating the system. You may also consider enlisting the help of a friend or family member to assist you in addressing the many details associated with health insurance and reimbursement for your treatments and health care.
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