Several weeks ago, we brought you the odd tale of how an Arizona woman, having survived breast cancer, was rebuffed by Anthem when seeking a simple blood test. Throughout her initial ordeal, Anthem seemed to have no problem covering expensive and ultimately successful treatments, but in its aftermath deemed some inexpensive blood work unnecessary.
After exhausting the carrier's appeals process, Heather Toplak turned to TV reporter Carey Peña for help. Ms Peña went to bat for Heather, and they successfully lobbied Anthem to both cover the lab work, and to change how they would deal with this issue in similar cases going forward.
The initial post raised some additional questions, however, and Ms Peña graciously agreed to forward my request for further information on to Ms Toplak; she has replied to my request, and given me permission to post this interesting (and hopefully useful) information. She writes:
"As of today, I have a clean bill of health. I still have a panic attack every three months before my check-ups, but I guess it can be expected.
I honestly think there are many more people with the same plan dealing with the same issue. Before my first chemo treatment last year, my oncologist ordered the standard bloodwork to be taken. A few weeks later, I received an invoice from [the lab] stating there was a balance due of $77 dollars for a CEA test. I checked my explanation of benefits statement...and there it was...denied. As so the saga began.
Hours on the phone with BC/BS, numerous letters from myself and from my doctor and three levels of the appeals process...once again left me with "denied."
What amazed me the most was that, during my conference call with the Appeals Board, my doctor told them this test is recognized by Medicare as being the standard for testing during breast cancer treatment. Their comment was it was a "gray area". The doctor said "There is no gray area...this is the standard for breast cancer treatment under national guidelines."
That is when I took the story to Channel 3. It was not a dollar factor. I felt they were denying preventative care.
Many oncologists insist on PET scans, ports, etc. These generate extremely high costs to the insurance companies. I have great veins, so no port was needed and my doctor felt a PET scan at that time was not necessary. They can have too many false positives. Great!! One less surgery and one less bill to the insurance company. I was approved to have a PET scan if needed. My course of preventative care is blood work every three months.
When you look at most insurance policies, they have a cap at about two million dollars. Two million dollars seems like a large amount to most Americans, but if you need re-occuring treatment, it adds up fast.
In comparative speaking....Lets buy the 3 million dollar plane, new condo and a few vacations and then ask for the bailout plan!"
I'll just add a few thoughts. Ms Toplak refers to the policy maximums, and she is quite correct (although many plans now have a $5 million limit). This is an issue with which most folks aren't familiar, but each time one has a covered expense under a given policy, the amount paid for it is deducted from that policy's lifetime max. Obviously, a few doc visits and flu shots aren't going to make much of a dent in that amount, but chemo, radiation and the like definitely will. Just something to keep in the back of our minds.
I'd like to thank Heather Toplak for sharing her story, and Carey Peña for covering it, and wish Heather continued good health.