How to handle insurance disputes

When I was diagnosed with rectal cancer many years ago, I quickly learned about the value of health insurance. The reality is, who can pay for the colonoscopy, CT scans and everything else entirely out of pocket? However, along with learning the positive aspects of health insurance, I also learned the problem areas.

By working on the Colorectal Cancer Alliance’s free helpline, (877) 422-2030, I have found other people are having problems too. What do you do when your insurance denies a claim? How about if a doctor who scrubbed in for your surgery is out of network? What about copays and deductibles? What if you can’t afford your medicines?  

I’ll tell you the answers.

Your Options for Handling Disputes

• Talk to your hospital or doctor’s office—maybe they didn’t code something correctly.
• Appeal directly to your insurance provider, because sometimes they make mistakes too.
• Speak with your HR representative if you have insurance through your employer.
• Contact your state’s insurance commissioner or department of insurance.
• Reach out to local news organizations that have a consumer reporter to voice your concern.
• Make social media work for you. Post on their page or tweet about the dispute. You’d be surprised how publicity can work in your favor. However, before taking to social media, it’s important to understand some common insurance-related terms.

Helpful Terms You Should Know

• Premiums are how much you pay each month for your insurance.
• Deductibles are how much you pay out of pocket per appointment, treatment or other matters before your insurance kicks in. Typically, an insurance policy with a high deductible comes with low premiums.
• Copays are what you pay per doctor’s visit or treatment.
• Cost sharing is when you pay a set percentage of the total cost of a drug or treatment, usually around 20 percent of the cost.  This is usually reserved for newer, higher priced drugs.
• Grandfathered plans are health insurance plans that had to have been in existence prior to March 23, 2010 and cannot make significant changes to your coverage.
• Preventative colonoscopy is a routine screening for colon cancer.
• Diagnostic colonoscopy is a screening for a symptomatic or high-risk person. Copays may be involved in a diagnostic colonoscopy.

Before You Begin Treatment

• Talk to your doctor and hospital about pricing.
• Don’t be afraid to shop around. It’s not uncommon that different facilities can have huge price differences for the exact same procedure.
• Make sure everyone is in network.
• Find out if you need to be pre-certified for anything.
• Ask about payment plans, especially if you have a high deductible plan.
• Insurance plans negotiate discounts with health care providers. If you have a high deductible plan ask your doctor or hospital if you can pay the insurance price.

Is Your Screening Covered?

• Preventative screening is required to be covered 100 percent in private non-grandfathered plans.
• Insurers cannot charge cost sharing for anesthesia that a clinician has deemed medically appropriate for a preventive colonoscopy.
• Kaiser Family Foundation has a webpage that keeps up to date on colorectal cancer screening coverage.

Finding Affordable Prescriptions

• Ask your doctor if there is a cheaper drug available.
• Contact the manufacturer to see if they offer patient discounts.
• Get support at the Colon Cancer Alliance’s financial assistance page.

If you are in need of support, please contact our free Helpline at (877) 422-2030. We’re here to help.