Medicare and Liver Transplants
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Lisacraine
I was told my Dr Stephans the radiologist that the insurance company has 10 days to respond. He says it really only takes them 2-3 days, but they stall.Lisacraine
My mother is waiting for insurance approval for radiation treatment at CCF. We recently had appt with Dr. Stephans and Dr Estfan. They are planning for the IMRT radiation about 6 weeks they said along with Gemzar chemo. I just called the office friday to check if insurance approval was obtained, they’re still waiting.I have a high deductible health plan, a PPO plan and about the only things for Tom that had to have an authorization was his scans. My ins. never delayed or denied anything for Tom. Other than having to meet the $4,800 and then the next $3,000 everything was covered by my insurance.
A lot of the required authorizations go on ‘behind the scene’ cause the doc’s/hospitals take care of them and the patient isn’t even aware unless there is an issue.
Margaret
Margaret, I appreciate your insights. I, personally, have never needed to deal with any of the insurance ropa dopa, which is inherent in HMO plans. I had conventional non HMO when I had a major cardiac surgery in 2001. In 2009 I had a resection, covered by Medicare, and last May a lung surgery, again covered by Medicare. I never have had to deal with any approval process at all, although the hospital may have on my behalf, but that was totally transparent to me and there’s never been a case of any procedure delayed. My take on medical insurance is for most people, PPO plans are probably best. HMO’s are OK for healthy people, but are not too great if you get a serious medical issue. Unfortunately, it’s not always possible to predict illness. I know people with cc and HMO’s and they must get approval for almost everything.
Jim:
Insurance Companies have a ‘Regional Medical Director’ who can make the final decision on if a procedure will be covered or not. In many cases, things can be held up if the insurance company does not have the Clinical documentation or the medical records that have been requested.
As long as the patients doctor’s are getting the information to the patients medical insurance in a timely fashion, a decision can be made in a timely fashion.
Ultimately it’s up to the patients doctor to submit either a pre-determination of benefits to the patients insurance company, along with any medical records that show why the treatment is medically necessary. Pre D’s can take 2 -3 weeks, but most providers do not submit them until 2 – 3 days prior to a procedure! That alone will hold things us.
If the provider’s office is calling the insurance companies Clinical Intake team every 2 – 4 days questioning for a follow up or if a decision has been made….they will be ensuring that it’s being worked on!
Margaret
Have you tried calling your carrier to find out where your planned treatment is at in their decision process? Most carriers have a doctor on staff who’s is the final authority on approval matters.
I have been waiting over a week for insurance to approve my radiation treatment and it is still pending. Does anyone know how to move this process along ?
We need to lean heavily on the Secretary of HEW to change this insane policy, if in fact, Medicare still disallows coverage.
Medicare used to require a ‘study’ for a cardiac patient to get an AICD (pacemaker/defibrillator). The ‘study’ included inducing an arrhythmia in the patient, with potentially fatal results. Medicare has since reversed itself on this crazy policy. The apparent genesis of this policy came about when some genius in the Social Security Administration realized that as many as 250,000 per year could benefit from the technology … then came the realization, “How are we going to pay for this?” Thus came the gatekeeper policy of a ‘study’. At the time I had to go through this nonsense, I wrote to my US Senators, Congressman and the Secretary of HEW. Only one Senator even had the courtesy to reply, but it was clear his aide who replied didn’t even understand the policy in question.
There are clearly some circumstances where transplantation for cc patients makes medical sense, and this needs to be forcefully presented to the appropriate administration officials. This is another case of the government denying effective and needed care.
The following link details liver transplantation covered/not covered by Medicare.
I googled “Medicare Cholangiocarcinoma transplant”.In 2006 my husband, who was 69, was considered a candidate for liver transplant due to cholangiocarcinoma. (Mayo Clinic, Rochester) Unfortunately his cancer had metastasized and he was therefore excluded from transplant.
However, while he was being considered, Mayo was very clear that Medicare would NOT cover transplant for his CC. We would personally need to put $100,000 up front.
Hope this helps clear up some questions.
Diane
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