Contest Carrier New Restriction on Annual Scan to Check Cancer Survivor?

Discussion in 'Employee Benefits Forum' started by yorkriver1, Aug 23, 2017.

  1. yorkriver1
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    yorkriver1 Guru

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    The group major medical certificate of coverage (ACA compliant coverage), which I forwarded to the insured EE, has instructions on how to appeal a carrier decision. I am interested in how often this is successful in your experience as benefits professionals.

    This group includes about 30 EE's,some are personal friends. Not that I would do any differently, but it's a sensitive matter.

    The carrier has declined to approve the annual scan for recurrence of cancer that my client has been used to receiving for the last at least 2 years.

    I assume the carrier has some internal guidelines they follow, and either they have tightened them up, or it's after so many years of remission, they spread out the approval of rechecks.

    Thanks in advance.
     
  2. adjusterjack
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    Wouldn't help you to know that because the carrier's decision is based on the terms and conditions of that carrier's contract and the particular claim of the employee.

    Yes, sensitive. That's why HIPAA limits your involvement in your employee's claim.

    You might get some general information from the carrier about that but nothing specific with regard to the employee's claim.

    All you can do is encourage the employee to appeal the decision. Nothing to lose. But, in the end, it's between the employee and the carrier.
     
  3. yorkriver1
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    "You might get some general information from the carrier about that but nothing specific with regard to the employee's claim.

    All you can do is encourage the employee to appeal the decision. Nothing to lose. But, in the end, it's between the employee and the carrier."

    Thanks, adjusterjack. Good information. I will be at a meeting with this group soon, & the EE will likely bring this up. I think the process of finding out about what the carrier in general may have changed could be pretty tedious, and even if known, the person could still appeal, so will see what the EE is motivated to do if it is mentioned. They have the certificate of coverage with how to appeal section.
     
  4. junkman
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    The 1st step is to find exactly why the carrier did what they did.

    Find out what documentation the carrier is using. The agent can have the group rep get the contract verbiage even if they have to address it as a "hypothetical" claim. The employee has access to any claim specific data and can conference the agent in.

    The employee can file an appeal after understanding the situation.
     
  5. yorkriver1
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    Good thoughts. When you say group rep get the contract verbiage, do you mean some internal information about claims metrics or do you mean the employee Evidence of Coverage document? I can and did get that. Sent it to the employee, too. 100+ pages. Includes how to appeal.

    Employee also willing to just pay for a scan, about $1200, which they would pay anyway, since deductible is $2,000. Just wouldn't count to MOOP.

    What I can't do is tell them what to do, only point out options, where to get more info. I will talk to the group rep, however, they have been good about claims related issues and explaining what the pitfalls are on the plans re: emergencies and out of network.
     
  6. junkman
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    The carrier paid based on how the claim was filed. Your only chance is to show that they had incorrect information.

    The most common examole is a wellness visit applied to deductible because it wasn't filed as wellness. You currently don't know what was filed.
     
  7. leevena
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    Reviewing the plan documents is a start but my guess is that they will not be all that helpful. Reading your post it occurs to me that this may be a medical policy decision, not a contractual one. It could be possible that the member does not meet the medical guidelines for this procedure. Ask for the guidelines, most reps will not know what you are asking for, so be persistent.
     
  8. yorkriver1
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    Thanks, good info. I also know from friends and family that scans for recurrence of cancer generally are paced over longer periods of time as the clean scans happen, they space out to longer intervals. The doctors say that usually during or after treatment, how often 1st 2nd 3rd year, etc. after 5 years, not as often, for example. It never occurred to me whether that is a generally accepted medical practice or if it's insurance. Also, insurance may use the generally accepted medical guidelines for their approval process. I will talk to my carrier reps, they are pretty sharp.
     
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