Heart of Oncology Nursing

When “No” Is Not an Acceptable Answer for Treatment

Denise Menonna-Quinn

transplantation, insurance, advocacy
CJON 2016, 20(5), 566-567. DOI: 10.1188/16.CJON.566-567

The focus of health care has moved toward prevention, and insurance companies are supporting preventive practices that enable their members to remain healthy. Many insurance companies have recorded healthy tips delivered by phone, employed case managers to assist patients in keeping physician appointments, created dedicated hot lines staffed by nurses, and developed resource centers. However, specific instances arise when insurance companies do not allow patients to have certain procedures because of contract language that was previously negotiated between the employer or individual and the insurance company. This was the case for my patient.

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    The focus of health care has moved toward prevention, and insurance companies are supporting preventive practices that enable their members to remain healthy. Many insurance companies have recorded healthy tips delivered by phone, employed case managers to assist patients in keeping physician appointments, created dedicated hot lines staffed by nurses, and developed resource centers. However, specific instances arise when insurance companies do not allow patients to have certain procedures because of contract language that was previously negotiated between the employer or individual and the insurance company. This was the case for my patient.

    The 48-year-old gentleman I first met last winter was a school teacher, active, and married with two children. He was diagnosed with multiple myeloma six years prior and came to my center to discuss the option of a second stem cell transplantation. Both the patient and his wife were highly educated and well versed about the disease process and treatment options.

    During our initial meeting, the couple was open and honest about their concerns that this second allogeneic transplantation would be denied by the insurance company. As the discussion progressed, I also became concerned about the coverage but did not want them to know I was apprehensive. I gathered all the information and devised a plan to obtain insurance authorization.

    The patient had a self-funded health insurance policy. Self-funded policies have both positive and negative attributes. In this case, there was more concern that the self-funded policy may actually work against approval for the patient. Allogeneic stem cell transplantations are costly, and self-funded policies may contain language that excludes the patient from having an allogeneic transplantation. Excluding coverage for allogeneic transplantations is a strategy used to decrease costs for the funds and its members.

    Unfortunately, this request for allogeneic transplantation was denied. As an insurance coordinator, one of the most distressing and heart-wrenching aspects of my work is informing a patient and family members that transplantation is not a covered benefit. Delivering this news was even more difficult and depressing because the transplantation was the only option for long-term survival for this patient because of his age.

    The day after I notified the patient of the news, the patient’s wife called, in tears, and said, “I can’t accept the denial and I will not give up without a fight.” I was overwhelmed by her passion and knew that we had to appeal this denial. In the denial letter, the insurer stated that no appeal process was available in this policy. Therefore, I spent the next two weeks working with the patient’s wife to figure out how to obtain authorization for an appeal process.

    The first step was that the patient needed the approval from the president of the fund to even start the appeal process, and still there would be no guarantee that the transplantation would be approved. Because of confidentiality, this part of the process needed to be handled by the patient’s wife. After two weeks of calling and sending appropriate documentation, the president of the fund finally gave approval to have the case moved to the appeals process. Luckily, this process included an independent review by three out-of-state physicians within the oncology specialty. We were ecstatic!

    I called to understand what was required for the appeal process and which method was best for submission. There were countless phone calls and a lot of time was spent waiting on hold to determine this information. However, with the assistance of the patient’s transplantation physician, we performed a detailed literature review, wrote a compelling letter, and sent all of the required clinical information.

    After faxing 92 pages to the insurance company, I had a heart-sinking feeling that this patient’s destiny would be determined by a pile of papers sent through a fax. I just kept hoping that the patient would be able to have his transplantation. At this stage, I was in daily contact with the patient and his wife to let them know the progress of the appeal process. We had to hurry up . . . and then wait.

    I checked the fax machine daily and, on day 14, I found 30 pages sputtering through. The documents were sent to my attention. My hands were shaking because I knew it was the response from the insurance company. Two out of the three reviews by the independent physicians included detailed reports of the reasons why this patient should have a transplantation. Therefore, the denial was overturned. He could have the transplantation! I was never so happy to call a patient and his wife and share the good news. The whole office cheered when the fax arrived because it was an emotionally charged process. This experience showed me that patients and their families often have unwavering will and perseverance.

    Nurses are patients’ advocates. We must learn to never give up and continue to fight for our patients no matter what obstacles are placed in front of us. “No” was not an option, and we did not accept it. I am thrilled to report that the patient had an uneventful and extremely successful allogeneic stem cell transplantation and is planning to spend the holiday season with his family.

    About the Author(s)

    Denise Menonna-Quinn, RN-BC, MSN, AOCNS®, BMTCN®, is a clinical level 4 oncology nurse and transplantation insurance coordinator at the Hackensack University Medical Center in New Jersey. The author takes full responsibility for the content of the article. The author did not receive honoraria for this work. No financial relationships relevant to the content of this article have been disclosed by the author or editorial staff. Menonna-Quinn can be reached at nursedquinn@yahoo.com, with copy to editor at CJONEditor@ons.org.

     

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