There are ways to learn if your health plan covers routine patient care costs in a clinical trial. Here are ideas about who to contact for help, questions to ask, and information to collect and keep if you decide to take part in a trial.
Work closely with your doctor. Ask your doctor if there is someone on his or her staff who can help work with your health plan. This person might be a financial counselor or research coordinator. Or, this person might work in the hospital’s patient finance department.
Work closely with the research coordinator or research nurse. Ask the research coordinator or nurse if other patients have had problems getting their health plans to cover routine patient care costs. If so, you might ask the research coordinator or nurse for help in sending information to your health plan that explains why this clinical trial would be appropriate for you. This package might include:
- medical journal articles that show possible patient benefits from the treatment that is being tested
- a letter from your doctor that explains the trial or why the trial is medically necessary
- support letters from patient advocacy groups
Helpful hint: Be sure to keep your own copy of any materials that are sent to your health plan.
Talk with your health plan. If your doctor does not have a staff person to help work with health plans, call the customer service number on the back of your insurance card. Ask to speak to the benefit plan department. Here are important questions to ask:
- Does the health plan cover routine patient care costs for patients taking part in clinical trials?
- If so, is a pre-authorization required? A pre-authorization means the health plan will review information about the clinical trial before deciding to cover the patient care costs.
- If your health plan requires a pre-authorization, what information do you need to provide? Examples might include copies of your medical records, a letter from your doctor, and a copy of the consent form for the trial.
- If a pre-authorization is not required, you don’t have to do anything else. But it is a good idea to request a letter from your health plan that states that a pre-authorization is not needed for you to take part in the clinical trial.
Helpful hint: Every time you call your health plan, make a note of who you are speaking with, the date, and the time.
- Understand all the costs related to the trial. Ask your doctor or the trial’s contact person about the costs that must be covered by you or your health plan.
- Work closely with your employer’s benefits manager. This person may be able to help you work with your health plan.
- Give your health plan a deadline. Ask your doctor or the trial’s contact person for a target date when you should start treatment. This can help to ensure that coverage decisions are made promptly.
What you can do if your claim is denied after you begin taking part in a trial
If your claim is denied, contact the billing office for help. The billing manager may know how to appeal your health plan’s decision.
You can also read your health insurance policy to find out what steps you can follow to make an appeal. Ask your doctor to help you. It might help if he or she contacts the medical director of your health plan.
Reproduced with permission from