Randy Montgomery

By proton-admin | August 14, 2018

 

“On July 27, I received 27 envelopes from Blue Cross Blue Shield, stating that my proton therapy claims had been paid in error, and demanded that the funds be returned.”

 


At first, I thought I had strep throat, but when antibiotics failed to subdue a lump in my neck, my doctor called for a biopsy. The next several weeks were a whirlwind of tests, results, consultations, and research. I had HPV oropharyngeal cancer.

A CAT scan revealed my cancer had originated in my right tonsil and affected three lymph nodes. I was told by experts that surgery would not be the best first option. Radiotherapy was prescribed, which would be enough to destroy my cancer, but would also expose surrounding healthy tissues and organs to radiation with life-altering side effects and complications. My dentist then suggested that I inquire about proton therapy.

I was told I was a perfect candidate for proton therapy by an expert physician and medical team at one of our nation’s leading cancer centers. At the same time, I was also warned that my insurer, Blue Cross Blue Shield (BCBS), would likely not authorize the procedure initially, but that the cancer center had a whole team of people who would initiate appeals on my behalf.

As predicted, a denial came from my insurer, and we fought through three rounds of appeals. After the second appeal, we were told that if we planned to appeal a third time, that their “intent is to deny,” indicating an unwillingness even to consider the individual facts of my case, and just rubber-stamping the denial. Despite my appeals being marked urgent – requiring a 72-hour response – BCBS failed to meet the deadline on at least two occasions, according to my care team. When an independent review panel also denied proton treatment, I felt defeated. My only options were to select traditional radiation therapy or find a way to cover my proton therapy treatment out-of-pocket. The denial process also delayed treatment by several weeks.

Running out of time and options, we sent a down payment to the provider so I could start proton therapy while continuing to fight for coverage. I also turned to my State Representative who submitted a “legislative inquiry” to the Texas Department of Insurance to ask about the prolonged response times on the denials from BCBS.

A few weeks after this inquiry was submitted, I was informed that the Enforcement Division at the Texas Department of Insurance was getting involved. Shortly after that, payments began to come in from BCBS, and within the next few months, it appeared that 27 out of the 33 treatment claims had been paid. At the same time, they were still sending out correspondence on the remaining six claims stating that they were not “medically necessary.” I was receiving paid claims one day, denials the next day; these mixed messages from my insurer left me confused about their policy.

On July 27, 2018, I received 27 envelopes from BCBS, stating that these claims had been paid in error, and demanded that the funds be returned. Otherwise, according to the letter, BCBS would be forced to withhold this amount from any future benefits to MD Anderson Cancer Center.

Utilizing everything we have at our disposal, my cancer center and I will continue to pursue authorization for payment from BCBS for treatment. Proton therapy was effective, resulting in a clean PET scan, with no follow-up surgery required. But despite my now being cancer-free, BCBS stands by their decision to deny reimbursement for my proton therapy.

My treatment was really tough, and I have had multiple professionals on my care team indicate that my complications and side effects would have been far worse had I been forced to receive conventional radiation.

I am incredibly fortunate and grateful that a treatment was available for my condition that offered fewer side effects and complications PLUS a successful outcome, but you should not have to resort to going into enormous debt to receive the treatment that you and your doctor agree on. Having health insurance should be enough.