Understanding the Ins and Outs of Health Insurance After a Cancer Diagnosis


As part of its Speaking Out video series, CURE spoke with Joanna Fawzy Morales, Esq., from Triage Cancer, about choosing and using health insurance before, during and after a cancer diagnosis.

Kristie L. Kahl: Why is it important that patients make sure that patients have adequate health insurance?

Joanna Fawzy Morales, Esq.: Well, we actually think that the primary contributor to the financial burden of a cancer diagnosis is having inadequate health insurance or even not having health insurance. But having health insurance doesn't necessarily solve that problem. Because if it has higher out-of-pocket costs, or doesn't cover your providers or the prescription drugs that you take, then that health insurance plan is pretty useless to you. And it is going to mean that you're paying more for your care out of pocket because your insurance plan isn't covering it.

Kahl: Absolutely. And so it can be overwhelming to figure out health insurance, in general. Do you have any resources that our patients can refer to? So that way they can choose the right health insurance plan for them?

Morales: Yes, absolutely. At Triage Cancer, we have a lot of resources to help people not only understand all of the health insurance options that are available to them, but also to figure out how you make choices among those options. And people often know about maybe one or even two options, but they might have three or four options. And we really want people to know about all of them, so that they can make educated choices about which plan is actually going to be best for them. And we have everything from five-minute animated videos to understand the basics of health insurance and how to pick a health insurance plan, two-hour long webinars that talk about health insurance options and two worksheets to actually help you do the math to figure out which plan is actually going to cost you the least by the end of the year.

Kahl: That's perfect. Can you explain how health insurance companies can be a barrier to care when it comes to cancer treatment?

Morales: Unfortunately, health insurance plans do throw up barriers to care. They're trying to keep costs down, which is understandable. But it can cause some really practical problems for patients who are just trying to get access to the care that's been prescribed by their health care team. And those barriers could be things like requiring prior authorization or pre-authorization, which basically is asking the insurance company for permission to get the care before you get the care. The problem is, is that they don't always give us a list of all the things that we would need prior authorization for. So what often happens is your health care team is going to prescribe care. And then they may check with your insurance company to see if they need prior authorization. But not every provider will do that for you. So it does fall on the patient to actually make sure that they don't need to get prior authorization from the insurance company first. Because if you don't, then your insurance company might deny the care. And then you're stuck paying for that care out of pocket.

And so, we always recommend that people ask before they get any care if they need prior authorization to get that care. And that's just one example. There are lots of other examples like requiring step therapy for prescription drugs where you have to try a lower-cost generic drug before you could get access to a brand name drug and then have to show that that generic drug doesn't work for you – either you're allergic to it or you've had an adverse reaction before you can get access to that brand name drug.

So all of these procedural hurdles actually just make it harder to get access to care and sometimes delay access to care. But if patients know what these potential hurdles can be and are communicating with their health care team, then you can jump over those hurdles a little bit easier, and get access to care faster.

Kahl: I know you mentioned with the prior authorizations, denials. So how can denials and appeals also affect the treatment timeline for patients?

Morales: It is also just one of those other hurdles. It's not uncommon for people to get denials from insurance companies, regardless of the type of care, so denials for surgery or a particular treatment or prescription drug. In all of those circumstances, patients can appeal those denials regardless of the type of insurance that you have. But if you have a private health insurance plan, like through an employer or an individual plan, not only can you go through the internal appeals process with an insurance company, but you also have access to external medical review, which means you get to go outside the insurance company to an independent entity and have them look at whether or not the care that's been prescribed for you is medically necessary. And on average, across the country, patients that actually go through the external appeals process are successful 50% of the time. So it's one of those situations where it's completely worthwhile to pursue it, even though you do have to jump through those extra hoops to get access to care. But unfortunately, there's data that shows that 99.9% of claims that are denied don't even get appealed to the first stage of appeals. And so this is actually a pretty important issue for us, because for the patients that are experiencing denials, and the 99.9% of them that aren't appealing, they're either are not getting access to the care that was prescribed by their health care team or they're paying for it out of pocket, which means that's contributing to the financial burden. And so we really want people to be aware that these processes exist. And these protections exist so that they can tap into them.

Kahl: Definitely. And so, we know that a cancer diagnosis is overwhelming to begin with. And then obviously, we add these hurdles that you've mentioned. So what is your piece of advice for patients who might be facing any of these issues, so that they can keep things moving in the meantime, after their diagnosis?

Morales: I think it's really important to talk to your health care team. So if you're having any challenges with your insurance, or you have any questions about how your insurance is covering your care, to communicate. So ask questions and talk to your health care team. There might be someone on that team who can have the answers for you. I think that you can always contact Triage Cancer, we have a legal and financial navigation program that is free where people can get answers to their questions about their insurance and other types of issues that they might be experiencing. And to really know that help is out there. And you can use the resources that are out there and not be afraid to ask for help.

Transcription edited for clarity and conciseness.

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