Cancer patients and their doctors should be fighting cancer, not insurance companies.
Unfortunately, too many patients are suffering undue health risks, anxiety, and financial hardship as they confront restrictive, complex, and unfair insurance review and appeal processes that drastically delay or make it impossible to receive treatments their doctors prescribe.
All patients deserve the chance to beat cancer. That’s why we are calling on state insurance commissioners to adopt principles of the Cancer Patients Timely Treatment Bill of Rights and hold insurers accountable for providing fair, timely, and transparent access to cancer treatment.
The Cancer Patients Timely Treatment Bill of Rights establishes principles that hold insurers accountable for providing what all cancer patients deserve:
PRINCIPLE #1: Coverage determinations must be made in a transparent process and based on accurate and up-to-date clinical criteria, including current literature and recommendations of medical societies. Clinical information used for coverage determination must be readily available to the prescribing physician, patient, and the public.
PRINCIPLE #2: Cancer patients and their providers must be notified of a health plan’s coverage determination within two days after the initial request for coverage.
PRINCIPLE #3: If an insurer questions the medical necessity, or the experimental or investigational nature of a health care service and is planning to deny coverage, the insurer must first provide the recommending physician (within the two-day requirement) a meaningful opportunity to discuss the patient’s treatment plan and the clinical basis for the insurer’s denial with a physician reviewer.
PRINCIPLE #4: The patient or a person acting on the patient’s behalf, or the patient’s physician may appeal any denial of coverage by telephone or in writing and the insurance company has three working days to act on that appeal.
PRINCIPLE #5: The insurance company is required to use a board certified medical oncologist, radiation oncologist, or surgical oncologist appropriately matched to the service being requested to make the decision on any expedited appeal.
PRINCIPLE #6: A final decision on any appeal must be made within three working days. After three working days, if a coverage determination has not been made on an expedited appeal, the requested treatment shall be deemed approved.
PRINCIPLE #7: If a cancer patient has been denied coverage for treatment, thereafter the patient may file a complaint with the state insurance commissioner.
The state insurance commissioner shall complete an investigation of the cancer patient’s complaint within 15 working days based upon information provided by the patient, their physician, and the health plan. If a health plan is found in violation of not providing coverage for services that are determined to be safe, effective and covered treatment by other health plans within the industry, the insurance commissioner may do any or all of the following things:
How you can take action: