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- Who
controls treatment decisions for cancer patients? The patient,
managed care insurance company, the pre-certification personnel,
the patient or the treating doctor?
- How do patients,
the treating doctor, or other health-care providers, obtain the
information necessary to define monetary health insurance benefits
available in a managed care setting?
- Contractual
roadblocks erected by the managed care health insurers to deny
or limit coverage/payment for cancer patients
- Exclusions:
We will not pay for bone marrow transplants, reconstructive surgery,
pre-existing conditions, etc.
- Limitations:
We will only pay for sixty days of chemotherapy treatments
- Definitions
- Medical
necessity
- Skilled
nursing benefit
- Custodial
care/plateau: Cancer has metastasized; patient is custodial
- Experimental
clauses: Insurance company will not pay/reimburse for:
- Bone
marrow transplant, immunotherapy, stem cell transplant,
biofeedback, pneumatic therapy for edema, etc.
- Practical
recommendations to overcome exclusions, definitions, limitations,
and experimental clauses
- Informed
consent and cancer trials: Everything you need to know but were
afraid to ask
- Living Wills,
durable power of attorneys: "Take control of your treatment:"
- HMO appeals
procedure: "Playing the winning game"
- Internal
Appeals
- External
Appeals
- January
1, 1999 Pennsylvania Legislation
- Trends
- Bad Faith
- Suits and
Legislation
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