Sarcoma Alliance Helps Patients Get Insurance Authorization

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The national nonprofit organization gives patients ammunition to get their insurance company to pay for referrals or second opinions from experts.

Arthur Beckert, executive director of the Sarcoma Alliance

Arthur Beckert, executive director of the Sarcoma Alliance

It's important to understand your health insurance plan, the process for seeking authorization, and the appeals process if they deny you.

The nonprofit Sarcoma Alliance has published a new web page to help people with the rare cancer convince insurance companies they need a referral or second opinion from a sarcoma specialist.

"Sarcoma gets misdiagnosed a lot," Executive Director Arthur Beckert said today. "Patients do better if they get diagnosed and treated by a doctor in a sarcoma center or one who has seen many, many cases.

"Unfortunately, some insurance companies don't want to pay for that. It can be difficult to get authorization in the same geographic area, outside the company's network of health-care providers. It can be even harder if you need to see an expert in another state."

That's not so unusual, Beckert says, because a number of states lack sarcoma centers. (The Alliance has just updated its page on sarcoma specialists.) Because so many people have to travel to see an expert, the Alliance created the Suzanne Renee Leider Memorial Assistance Fund, which can reimburse patients up to $500 if they need a second opinion, he says.

"It's important to understand your health insurance plan, the process for seeking authorization, and the appeals process if they deny you," Beckert says. "It can help to have a scientific basis for your request. On our new page, we have citations and links to studies."

When asking for a second opinion or referral, he suggests:
-- Be clear that you are asking only for services that are the “standards of care” for sarcoma and are “generally accepted practices in medicine.” You can give them the citations for scientific studies on the Alliance page.
-- State that the services are consistent with those recommended by national guidelines, and give them the links provided by the Alliance.
-- You may want to say that it is “medically negligent” to withhold these services, which raises serious liability issues for the company.
-- In general, you should not argue that you need some experimental treatment or want to participate in a clinical trial, as this may complicate the issue. Once you get a second opinion, if the doctor recommends a clinical trial, that will involve a separate call to the insurance company.

Sarcoma is a cancer of connective tissue, including bone, muscle, cartilage, fat cells and nerve tissue. It can arise in any part of the body at any age, from newborn on up. It represents 15 percent of cancer cases in children and 1 percent in adults.

The Alliance, based in Mill Valley, Calif., provides information and support to people affected by sarcoma, and connects them to one another. For more information, go to http://sarcomaalliance.org.

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