Payers Manipulate Definition of Necessity

Steven J. Frank, MD
Published: Thursday, Sep 29, 2016
Steven J. Frank, MD

Steven J. Frank, MD

When it comes to health coverage, most Americans face an unnerving reality—they have no idea what is covered under their health insurance policy until they are affected by illness or disease. Further complicating matters are the often-illogical reasons why certain treatments are covered by some insurance providers and others are not.

As an oncologist at MD Anderson, one of the world’s leading cancer centers, I have found that these unexplainable discrepancies in insurance coverage inhibit physicians from prescribing and prevent patients from receiving the most appropriate treatment for their illness. In addition, these problems are far too common in the field of proton therapy.

Imagine that you are a patient who has just received a diagnosis of cancer. Once you have recovered from the initial shock of hearing that diagnosis, you consult a doctor about the path that lies ahead. A medical team consisting of a surgical oncologist, a medical oncologist, and a radiation oncologist weigh the most recent clinical evidence to date and prescribe proton therapy to treat the cancer. This seems like great news, because proton therapy involves less radiation exposure to surrounding healthy tissue than conventional photon treatment.

However, your insurance company suddenly slams on the brakes. Without giving you a reasonable explanation, it refuses to cover proton therapy. Or, equally bad, the company says the treatment is not “medically necessary” and is “experimental,” which goes against the guidance of an informed group of the world’s leading oncologists. The fear, disappointment, and frustration are indescribable—now, your focus must shift from preparing for a life-changing battle against cancer to fighting your own insurance company.

Payer Negotiations Cut Into Time for Patients

Picture the same scenario from the doctor’s perspective—something I experience time and again. As a physician, I am frustrated when insurance companies respond with indifference toward what our oncology team and other experts in state-of-the-art cancer care have considered and recommended. Not only are my patients denied care that is critical to fighting cancer, but now I must take time away from other patients to get on the phone and start lobbying with the insurance company that has declined to pay.

For each individual patient denied coverage, I explain our medical team’s cancer care management plan to the insurance company. I also tell them about the published data that supports our decision. Insurance company representatives usually have little-to-no experience with oncology, let alone knowledge of highly advanced forms of radiation or proton therapy. Consequently, patients’ access to cancer treatment is often limited by insurance panels that do not understand proton therapy or have expertise in the field of radiation oncology. During the so-called “peer-to-peer” review of each patient’s case, these panels simply quote their insurance company’s medical policy and move the case to another step in the complicated, multilayered, and lengthy appeals process. Most patients do not have the time and inclination to navigate the insurance process on their own time or the knowledge to prove that the treatment recommended for them is indeed medically necessary.

Who Defines “Medical Necessity?”

Each insurance company tends to have a unique definition of “medical necessity,” and this is the heart of the problem for patients and doctors alike. Patients, physicians, and policy makers seem unaware that the definition of “medical necessity” is not standard and can be changed at the whim of each insurance company. This definition is critical: if the cancer treatment recommended by the oncology team does not fit the policy definition of “medical necessity,” then the recommended treatment will be considered “experimental and investigational” and will not be covered. The burden of assuming the financial risk for treatment thus is shifted from the insurance company to the patient.

So what does “medically necessary” really mean? It is impossible to tell, because the evidence used by insurance companies varies widely and changes often. Why should insurance companies—whose judgement may be affected by the desire to save money—be allowed to define what is medically necessary for cancer treatment?

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