Outcomes4Me met with Monica Bryant, attorney and Chief Operating Officer at Triage Cancer, to discuss how to navigate your finances while living with breast cancer. Triage Cancer is a non-profit that provides education on the practical and legal issues that can arise after a cancer diagnosis. We have included the entire webinar video above for anyone who missed it and wants to watch it in full.
Here is a recap of the key takeaways from the discussion with Mrs. Bryant:
We’ll start with an overview of the financial challenges breast cancer patients may face and the resources that exist to help patients handle them.
When we talk about navigating finances, the term financial toxicity has become popular over the past few years. This relates to the financial burden or stress that a cancer diagnosis can cause. I believe the most significant contributing factor to financial toxicity is health insurance status. This can mean not having health insurance, not having the correct health insurance policy for you or not understanding how to effectively use the policy you have.
One of the challenges with health insurance is that it is incredibly confusing. One survey found that only 4% of Americans could define the four most common terms used in health insurance policies. If people don’t understand the words being used, we can’t expect them to be good consumers. The most important terms are:
- Annual Deductible: A fixed amount you have to pay each year before your insurance starts picking up their share of the costs
- Cost share / co-insurance: The percentage of the total cost you pay each time you receive care. If you’re plan is 80/20, once you’ve paid your deductible, the insurance company will start picking up 80% of your bill and you are responsible for 20%
- Co-payment: A payment that varies service to service, for example $25 to see your doctor or $35 to see a specialist
- Out-of-pocket maximum: A fixed dollar amount that is the most you should pay out of pocket for healthcare costs per year. In general, after you reach the out of pocket maximum by paying your deductible, co-insurance and co-payments, insurance will cover 100% of all healthcare costs
As I mentioned, it’s not just about having health insurance, it’s about making sure people are effectively using their health insurance policy. When people have health insurance and they receive a medical service, a claim gets submitted with the insurance company. The insurance company may come back and say the claim is denied, meaning they won’t cover it. If consumers take that at face value, they may end up paying more out of pocket than they are supposed to. We want people to understand that they don’t have to take no for an answer.
As consumers we have the right to appeal those denials. We know that, just in the State Health Insurance Marketplaces, over 40 million claims are denied per year and less than 0.2% are appealed. We also know that when people appeal 40-60% of appeals are decided in favor of the patient. Therefore, about half the time the insurance company says they don’t cover something, they are wrong. I recognize that appealing denied claims is easier said than done, but Triage Cancer has many free resources to help you navigate the appeals process.
What happens if you overpay insurance companies? Why don’t they pay you back? Can you request payment back if an appeal was found in your favor?
If you win an appeal, but have already paid a certain amount to the provider, you can certainly go to the provider and try to get the money back. However, it does pose a practical issue. You just finished battling the insurance company and now you still have to get money back from the provider. That is why the rule of thumb is to not pay any medical bills until you get an explanation of benefits from the insurance company explaining what they are or are not going to cover. If the explanation of benefits says your insurance won’t cover the bill or won’t cover it at as high a rate as you expect, that is your opportunity to appeal. You shouldn’t pay the bill while you’re in the appeal process. It is incredibly important for you to let your provider know, “I’m appealing the bill with my insurance. Please push back the due date or make a note in my file that the payment is pending appeal.” In summary, communicate with your provider, keep records of all your conversations and appeal before paying the bill to avoid having to get money back from providers.
Do deductibles increase every year? Do you have to pay the deductible every single year? Do you pay yearly or every 6 months?
You pay your deductible yearly. You pay towards that deductible with most of the services you get until you’ve met it. If you have a calendar year plan, starting January 1st everything goes back down to zero and you start over. Plans can absolutely change each year so it’s important to review the deductible at the start of each year. I will add that some plans have a separate deductible for prescription drugs meaning you pay towards one deductible for medical services like doctor’s visits and another deductible for prescription drugs. Both are annual deductibles.
If you are looking for more support, resources, or have additional questions, submit your question using the “+” button on the 4Me tab and clicking on “Ask Outcomes4Me” in the Outcomes4Me app. Our O4ME clinical care team will do their best to help you find an answer.
