Insurance: Your Personal KGB

As soon as you have the slightest hint that breast cancer lurks in your future, call
your insurance company. Get the name of a representative whom you can call on a
regular basis. On the first page of your notebook, right below your doctors’ names
and numbers, write this person’s name, direct phone number, and toll-free number.
Explain your situation and ask for advice. Start a file (might as well make it a big one)
in which you will keep track of every call, every question answered, every direction
given—along with the date, time, and name of the person to whom you spoke.
Plan to keep five insurance-related files: bills, receipts, claims filed, claims pending,
and claims paid. In another folder keep letters: those from your medical team ex-
plaining the necessity for a given procedure, requests for sick leave, and any corre-
spondence about insurance. Better yet, since you are already stressed to the limit,
turn this task over to someone you trust to keep detailed records—husband, adult
son or daughter, or paid professional, such as an attorney or accountant.
Your primary concern, of course, is what your insurance will and will not pay. If
you’re past age 65 or have been permanently disabled for 30 months or more, Medi-
care will help pay your bills. It does not, however, pay all hospital expenses (you
have a co-payment and an annual deductible), so call your Social Security office
(1-800-772-1213) if you have questions. Even if you have Medicare, you probably
have some kind of supplementary health insurance.
Whether you are dealing with your primary insur-
ance, Medicare, or supplementary insurance, here
are questions you need answered:
➤ Will my insurance pay for second opinions?
➤ Are second opinions required?
➤ Will it pay only if I am treated by certain
doctors or surgeons, or treated in certain
medical facilities?
➤ Does it require “evidence of medical neces-
sity” before it will pay?
➤ Will it pay for any experimental treatments
and/or off-label drugs?
➤ What is my co-payment?
➤ Is there a maximum payment?
➤ Are any treatments excluded from my policy?
➤ Do I need a pre-authorization number for each doctor’s appointment, surgical
procedure, or follow-up treatment?
➤ Do I need any special forms?
➤ Are there any deadlines, such as notice prior to surgery or filing deadlines?
When you get answers to these questions, add the details to your notebook. The an-
swers will most likely influence your decisions about who, what, when, and where. De-
tailed records can eliminate major stress in the immediate and more distant future. I
know families who, a year after treatment, are still trying to unravel insurance tangles.
Be ready to fight if necessary. Let your medical team know about any battle with your
insurance company, especially if your doctor/surgeon recommends a procedure or
treatment and your insurance company reneges. Accustomed to dealing with the
technical vocabulary and innumerable quirks of insurance policies, your medical
team can often move boulders when you can only move pebbles. Sometimes insur-
ance companies that have been reluctant to pay get a much-needed nudge by your
telling them you’re calling your lawyer. If that doesn’t work, let your fingers do the
walking, make the call, and get that letter from your lawyer; sometimes it’s enough
to start things rolling.
Medical assistance is available for people under a certain income level. Talk to your
hospital social worker, hospital financial counselor, or cancer hotline. Organizations
like the American Cancer Society also offer assistance. Don’t hesitate to check them
out.