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 appropriately 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: Approval and denial 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 these determinations must be readily available to the prescribing physician, patient, and the public.
Because insurance companies often use third parties to help make approval or denial decisions, the relationship of these third parties, including the methodology used to select such vendors, payments made on a per case basis, the methodology used by the external vendor to review submitted case information, incentives for denial if any, and the external reviewer’s conflicts if any must be openly available for review in the public domain.
PRINCIPLE #2: Cancer patients and their providers must be notified of a health plan’s approval or denial determination within 24 hours after the initial request is made.
PRINCIPLE #3: If an insurer questions the medical necessity, or the experimental or investigational nature of a health care service and is planning to issue a denial, the insurer must first provide the recommending physician (within the one-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. A lack of reviewer familiarization with the relevant data cannot be a basis for denial.
PRINCIPLE #4: The patient or a person acting on the patient’s behalf, or the patient’s physician may appeal any denial decision by telephone or in writing and the insurance company has four 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 four working days. If an approval or denial determination has not been made on an expedited appeal at the end of business on the fourth day, the requested treatment shall be deemed approved.
PRINCIPLE #7: If a cancer patient has received a denial determination from his or her insurer, 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; the health plan’s review process, confirmation of the specific documents reviewed, and written findings of the review will be considered required submissions and must be provided immediately. If a health plan is found in violation of not providing either the appropriate documentation in a timely manner, or appropriate approvals 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:
PRINCIPLE #8: While employer self-funded plans are not regulated by state insurance commissioners, we call upon these employers to adopt the Cancer Patients’ Bill of Rights and enforce it with any insurer that administers their plan.
How you can take action: