A bumpy road called health insurance…
This road for the clinical trial has been bumpy to say the least. I haven’t even started down the path of the trail and I need a new suspension already…..due to my “wonderful” insurance. It started about 7 weeks ago when I first called my insurance and asked if they covered clinical trails. The 1-800- number answer was a very emphatic NO!!!!!!. The following week I was speaking with our Town’s HR representative about getting a care champion assigned to my case so I could weave my way through the bills easier. I told her what had happened and she said she would look into it. Her answer from her contact was that our insurance will cover clinical trials, but there are very specific parameters. Oh joy.
The next week I was assigned my care champion and I asked what information they needed to approved a Phase III clinical trial.Ironically she said nothing except the Dr. to call and establish a medical need. That was a sign of relief…..slightly premature however. This is when I started the very bumpy and curvy road of health insurance hell. My Dr. submitted the request, easy enough right. NOT. Then the insurance said they needed to know which of the 2 medications I was going to go on. It was explained to them that I had to have a full work up done to qualify me for the trial. Then and only then could they assign me a drug. The problem was, once I get randomized I have to start the drug within 2 to 5 days. Not enough time for prior authorization. So then they needed information on the clinical trial. This started the phone call and fax sending barrage which resulted in me receiving a letter saying they were denying the preliminary test to enter the trial. What the hell!!!! The trial should be fairly straight forward for the insurance company. Arm “A” is the standard treatment for stage III melanoma. Arm “B” is the trial drug and would be significantly cheaper than arm “A” . This is because the trial pays for the drug, which $90,000 a dose and there is only 8 IV treatments throughout the year. Arm “A” has 20+ IV treatments and 3x/week subcutaneous injections for 11 months. If should be a simple decision of math. Either they end up paying the standard treatment or save money. I am now convinced that the insurance industry is made up of a bunch of politicians who can’t think their way out of a bucket.
So I spent the last two weeks trying to figure out how to get this resolved. Apparently no one in the insurance world can talk to each other or enter anything in a computer file. It finally came to a head when I was speaking to an individual who said they didn’t have any record of a clinical trial request and my Dr was told my plan doesn’t approve clinical trials. This is where we lose our suspension and I blew my top. I proceeded to call the appeals line and explain to them I have the documentation showing that my plan does approve clinical trials and copies of all the faxes that were sent to them of information they needed.
There goes the rug under my feet!! The person on the other end of the phone line stated that my denial went to a peer review ( something that was not noted in the denial letter) and it was approved ( at least the Ct’s, MRI’s and blood work). I was speechless….( insert your comment here about how hard that is to believe). I quickly got the approval number so I could reference it in the future. Needless to say I am amazed at lack of communication that exists in the insurance world. I really felt I needed Matt Damon and Danny Devito from “The Rainmaker” for a while. I’m glad at least portion of the trip is done and that the suspension has been replaced. Lets hope for a smoother ride.
