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Home > Patient Services > Case Management > Insurance Appeals, Pre-auths, Coding & Billing

How PAF Assists Patients with Insurance Appeals, Pre-Authorizations, and Coding & Billing Issues

Insurance Appeals

An insurance appeal is a written request submitted to the insurance company involved, by the patient, the patient's appointed representative, or in some cases, the patient's doctor, to have a decision of denial for drugs and/or treatment overturned. (Simply stated, a denial means that the insurance company has decided not to pay for the procedure or therapy that your doctor has recommended.) The services may have already been performed or may be scheduled in the near future. If the denied procedure has not yet been performed, the insurer may be denying the request for pre-authorization. PAF case managers assist patients through the appeal process to allow the patient to be heard and provide any and all necessary information to convince the insurance company to change their decision and provide coverage for the procedure.


Pre-Authorization

Pre-authorization is a term used for obtaining prior approval from your insurance before having a procedure done; however, many times due to an unforeseen circumstance, you may not have control over medical care provided requiring prior approval from your insurance. If your insurance company is denying payment due to lack of pre-authorization, PAF's Patient Services Department case management team assist. Our medical billing specialists can help resolve claims that were denied due to pre-authorization issues.


Coding and Billing

Do you think that you have been overcharged or billed incorrectly for medical services? Your information will be reviewed by a professional case manager who will be the liaison between you, the provider and your insurance company to help find a positive resolution for your issues.



Medical Debt Crisis Assistance



Medicaid is a government program that provides medical and health related care to specific groups of people in the United States. Each state sets its own Medicaid eligibility guidelines. Medicaid is geared toward individuals with low incomes, but eligibility also depends on meeting other requirements involving age, pregnancy status, disability status, other assets and citizenship. The Patient Advocate Foundation’s case management staff is able to help patients with Medicaid related needs including education on eligibility, the application process, and assisting with unpaid medical debt.




Medicare and Medicaid Help



Nearly one in every four Americans is enrolled in Medicare or Medicaid. These are the programs which provide health care for the aged, disabled, and indigent population administered by the Centers for Medicare and Medicaid Services (CMS). Because of its wide reach, trying to find the answers to your questions can often turn into a daunting experience.

So where does one begin the search for information for his/her needs? Here are some resources that you may find beneficial in your quest for knowledge and answers. Some of these are government resources while others are from third parties.

Medicare.gov, the Official U.S. Government Site for People with Medicare, is a good place to start. This site is written with the consumer in mind, and provides easy-to-use tools to help you find what you need. Among them are:For Medicare recepients who are researching whether a specific procedure is covered, there is the Coverage Issues Manual. The manual addresses coverages issues for clinical trials, medical procedures, supplies, diagnostic services, prosthetic devices, and nursing services.

Medicare Primer
This booklet is designed to familiarize individuals with the Medicare program with an emphasis on prescription coverage and utilization. The primer contains:
  1. An overview of the Medicare program, its growth over time, and its new structure under the Medicare Prescription Drug, Improvement & Modernization Act of 2003;
  2. A description of the most significant parts of the new Medicare prescription drug law.
The Center for Health Dispute Resolution (CHDR) operates the nation's largest system for the resolution of health insurance appeals through independent external review. The organization can help persons enrolled in a Medicare + Choice (Medicare HMO) plan when the company operating the plan decides to uphold its initial determination on the need of emergent or urgent services. These are services that the beneficiary feels should be covered by Medicare or by their plan, or any services the beneficiary believes should be provided by the plan. More information is available on their Medicare page.

NeedyMeds.org is an information resource where people can learn about patient assistance programs and other programs designed to help those who can't afford their medicines. The site includes an extensive list of drugs and programs, a comparison of pharmaceutical company discount card programs, and information on how to apply for patient assistance programs.

There are also resources here that may be beneficial to you in your quest for knowledge. They can be found in the Resources section or you may go directly to them by clicking the links below.
  • The Managed Care Answer Guide helps people make decisions about choosing a health care plan. It is also designed to assist consumers in understanding parts of their health care plan that may be confusing once they have made health insurance choices.
  • Your Guide to the Appeals Process features sample appeals letters, specific strategies to use when negotiating the internal and external appeals processes and specific instructions to follow when all appeals have been exhausted.
  • The State by State Financial Resource Guide contains information for patients seeking financial relief for a broad range of needs including housing, utilities, food, transportation to medical treatment, and children's resources.





National Coverage Analyses
Non-Autologous Blood Derived Products for Chronic Non-Healing Wounds
Posted proposed decision memorandum.


Medicare Approved Facilities
Carotid Artery Stenting Facilities List
New facilities added.



Clinical Trial Barriers



Cancer clinical trials have brought enormous advances in the areas of cancer prevention, treatment and diagnosis. However, less than 5 percent of adults diagnosed with cancer each year will get treated through enrollment in a clinical trial. With broader enrollment, the effort to find new and better ways to treat and prevent cancer might be swifter.

But, as suggested by two surveys and a series of focus groups, the vast majority of cancer patients are unaware of clinical trials and physicians aren't enrolling patients because they don't have the time, staff, or funding to do so.

"Any improvements in cancer care come from clinical trials," said Ezekiel J. Emanuel, M.D., Ph.D., chair of the Department of Clinical Bioethics at the National Institutes of Health and author of a 1999 study of oncologists' involvement in clinical trials sponsored by the American Society of Clinical Oncology (ASCO). "If we want to speed up trials and get more data, everybody involved - researchers, funders, and patients - can do more."

Missed Opportunities
In one survey completed in spring 2000 by Harris Interactive, Inc., eight out of 10 cancer patients were unaware that clinical trials could be an option for them.

The Harris survey included 5,980 cancer patients, 935 people without cancer (including 200 African Americans and 200 Hispanics), and 425 primary care physicians and oncologists. The survey was sponsored by the Coalition of National Cancer Cooperative Groups, Cancer Research Foundation of America, Oncology Nursing Society, and Cancer Leadership Council, an umbrella organization of patient advocacy groups.

Of the unaware patients, 76 percent said that if they had known about clinical trials, they would have been somewhat or very receptive to participate.

Members of the public showed a strong willingness to participate in clinical trials if they were diagnosed with cancer. Eight out of 10 said they would be willing to participate for their initial treatment. Almost nine out of 10 would be willing if their initial treatment failed.

Myth versus Reality
However, this enthusiasm did not carry over to patients facing real-life treatment decisions. Of those patients who knew about clinical trials, 71 percent chose not to participate.

Their reasoning was based mainly on misconceptions: fear of getting a placebo in place of actual treatment, belief that standard treatment is better than what they would be offered in a clinical trial and fear of being a "guinea pig."

In fact, placebos are rarely used in cancer treatment trials, and never in lieu of standard treatment, according to Robert L. Comis, M.D., president of the Coalition of National Cancer Cooperative Groups and chairman of the Eastern Cooperative Oncology Group in Philadelphia.

The concerns expressed by respondents who chose not to enter a clinical trial were not borne out by those who participated. The vast majority of patients surveyed by Harris who had participated in clinical trials said their experience was positive. Ninety-seven percent said they were treated with dignity and respect, and received excellent or good quality care. Eight out of 10 said they were not treated like guinea pigs and were not subjected to more tests and procedures than they thought necessary.

Three out of four said they would recommend participation in a clinical trial to someone else with cancer.

One in five non-participants said they were concerned their insurance might not pay. But for those who enrolled in clinical trials, 79 percent said their insurance company ultimately paid for the care they received.

"Fear is a greater barrier than the reality," Comis said.

Physician Bottleneck
In the Harris survey, most of the patients (67 percent) who participated in a clinical trial said that a doctor had a great deal of influence on their decision to participate. This means that barriers for doctors need serious attention.

The physician respondents to the Harris survey had very positive attitudes about clinical trials. Ninety percent of oncologists and more than 70 percent of primary care physicians said they believed clinical trials should be offered to patients at all stages of treatment, not just when standard treatments have failed.

In the second survey, sponsored by ASCO, the oncologists who responded were strong supporters of clinical trials. About 85 percent said they viewed clinical trials as the essential means of discovering new therapies to improve patient care.

On first glance, the 3,550 physician respondents to the ASCO survey appeared to have been active clinical trial recruiters. Eighty percent said they had enrolled a patient in a clinical study during the past three years.

But actual patient enrollment was far from ideal. The oncologists stated that 20 percent of their patients were eligible for a clinical trial. They approached half of those patients about enrolling, and just half of those, or 5 percent of their patients, were actually enrolled.

According to the ASCO survey, the big barriers for physicians relate to time, staff, and resources. Clinical trials involve more intensive collection and filing of patient information and data. In addition to the extra paperwork, sometimes staff may need additional training to complete necessary forms.

The cost to physicians for data management and other research expenses associated with enrolling a patient in a cancer clinical trial (Phase III) is about $2,000, according to the ASCO survey. Two-thirds of physicians also said eligibility criteria for patients are too restrictive.

When asked what would help them enroll patients, oncologists gave high marks to reduced paperwork, assured reimbursement of patient care costs, and more data management help. Protected time to do research appeared important as well. Those with protected time were more than twice as likely to enroll more than 5 percent of their patients on trials.

Role of Primary Care Physicians


Ninety percent of the primary care physicians who responded to the Harris survey stated they would like to see more of their patients participate in clinical trials. But a third study, suggests that primary care providers may not feel suited to handling clinical trial matters. In a series of NCI-sponsored focus groups conducted during June and July of 2000, 48 primary care physicians and nurse practitioners discussed their views regarding clinical trials.

Most of this group believed that oncologists were better suited to discuss cancer clinical trials with patients. The primary care providers didn't feel they had the time to learn about studies, discuss them with patients, or do the necessary paperwork. Some had the perception that clinical trials are inferior to standard care, appropriate only if other treatments fail. Also, many had misconceptions about placebos, concerned that their patients would be assigned to receive no treatment. Only one thought patients might get better care by participating in a trial.

However, primary care providers did express a strong interest in learning more about trials studying the prevention of cancer, such as the Study of Tamoxifen and Raloxifene (STAR) to prevent breast cancer. They thought that if they had easy access to information about clinical trials in their local area, especially prevention trials, they would be better equipped to discuss trial participation with their patients.

Time for Action
"These surveys have defined the issues," Comis said. There is "enough information to move" toward three obvious targets: "We have to raise the level of awareness among patients and doctors, address the real, legitimate problems of the doctors, and bring the level of resources up to what is required."

Public awareness programs on cancer trials are being planned by the partners of the Summit Series on Clinical Trials, a group working to improve the understanding of cancer clinical trials and the National Dialogue on Cancer, a group that brings together principal leaders of key national cancer organizations, agencies and institutions from the public, private and non-profit areas.

The National Cancer Institute (NCI) is doing its part, too. Under a new national system, the NCI hopes to change the way it develops, conducts, reviews and supports clinical trials.

Part of this new system includes the Cancer Trials Support Unit (CTSU),which is designed to make it easier to enrollment patients into clinical trials. The CTSU provides participating physicians with a single access point to the NCI's entire phase III clinical trials system, and helps with access to protocols, training, and educational information. Additionally, NCI is developing education initiatives to better inform physicians, nurses and the public about clinical trials.