Negotiating Insurance Coverage For Molecular Profiling

“Is It Covered?”

That’s a question that everyone in the US with health insurance asks all the time, about everything from routine doctor’s office visits to complex cancer care. If you’re dealing with a cancer diagnosis, and want to take advantage of precision medicine options like molecular profiling of your cancer, you’ll need to negotiate with your insurer to get to “yes, it’s covered.”

In case you were wondering, this is new territory for both patients and payers. Negotiating with your insurer can not only deliver a benefit to you, in the form of coverage, but it can also start establishing precedent and practice for patients who come after you.

Two years ago (March 2015), in Applied & Translational Genomics, Nabil Hafez of Quest Diagnostics published an article titled, Precision Medicine is Here, Break Out Your Wallet, where he outlined the challenges oncologists and payers faced when trying to determine coverage. Hafez pointed out the development of CPT 2013, the medical billing principle of code stacking, that opened the door to more coverage of genomic testing for a variety of conditions.

You can put this information to use in your own negotiations with your insurance company. Let’s walk through that process, shall we?

Let’s Make A Deal, Health Insurance Edition

Here are your dance steps in the Let’s Make A Deal mambo:

  • Review your insurance plan with your oncology team.
    • The practice’s billing manager is the best place to start, and you should also ask for their recommendation on a cancer navigator, if they don’t have one on staff. Cancer patient navigators – the link takes you to a great explainer on the American Cancer Society’s site – can help you navigate treatment options and negotiating with your insurer. They can also help you find payment options outside insurance coverage, if that becomes necessary.
  • Find out what genomics testing labs your oncologist uses for molecular profiling of cancer tumors and plasma.
    • If your oncologist doesn’t have any preferred labs, you can share this list of Cure Forward diagnostic testing partners.
  • Get the CPT (Current Procedural Terminology) codes your oncology team will use to submit insurance claims for your molecular profile testing.
    • CPT codes are the billing numbers that every medical provider uses to bill insurers for the medical care they deliver. You can take a deep dive into them here, courtesy of the Medical Billing & Coding site. Remember the CPT 2013 “stack codes” referred to above? Here’s where you can look for them, using the CPT codes Nabil Hafez referred to in his article.
  • Talk to the testing labs your oncology team uses to see if they’re in-network with your insurer – this will give you a negotiating chip.
    • An “in-network” lab will know the billing codes and protocols your insurer uses. If they’re in network, and they have a CPT code for the tests your oncology team is ordering, use that information to start bargaining for coverage.
  • Be aware that most insurers still classify molecular profiling of cancer tumors as “investigational and not medically necessary,” meaning they’ll initially deny coverage for this type of testing.
  • If you do wind up against a brick wall of “claim denied,” be aware that most genomic testing labs have a patient assistance program to help people pay for molecular profiling of their cancer.
    • And if you’ve already established a working relationship with a cancer navigator (first bullet above), this is another area where they can be of help.

This Is Hard, But It Can Be Worth It

If you think this seems like a lot of effort for someone dealing with a cancer diagnosis, and all the decisions that diagnosis entails, you’re right. However, since the US healthcare system relies on health insurers to manage paying for medical treatment, including determining what medical treatment they’ll pay for, this is a required process.

On the plus side, you won’t have to walk this path to “covered, or not?” alone. Your oncology team has experience in dealing with insurer appeals, as will the testing facilities that will help you and your care team determine the right treatment pathways for your cancer. If you wind up with a “claim denied” situation, talk to your oncology team, and get your cancer navigator involved, too, if you’ve got one.

Precision medicine will deliver better care, likely at lower cost, over the next decade. For those people who will be at the front of that wave –  like people with cancer diagnoses seeking targeted treatments and the clinical trials that uncover them – the process will require negotiating past “no” frequently. Being prepared for that, and working to assemble a team to help you get the testing and treatment that will get you to “No Evidence of Disease,” is a must for your cancer journey.

Getting precision medicine treatment for your cancer is a challenging journey, both physically and mentally. Negotiating the payment for it does add to the challenge, too often, but you’ll be a pioneer. All who come after you, seeking the same treatment, could see their lives saved because you fought to get your treatment covered. Precision medicine mints cures … and heroes.

Get sequenced. Get answers. Get help.

Casey Quinlan Precision Medicine Advocate

Casey Quinlan Precision Medicine Advocate

Casey Quinlan covered her share of medical stories as a TV news field producer, then got a breast cancer diagnosis five days before Christmas in 2007. She used her research, communication, and comedy skills to navigate treatment, and wrote “Cancer for Christmas: Making the Most of a Daunting Gift” about managing medical care, and the importance of health literate self-advocacy.Her speaking calendar for 2016 includes Academy Health’s National Health Policy Conference, the 7th Patient Engagement, Education and Adherence Summit, the ePharma Summit, the Genetic Alliance’s Building Trustworthiness in PCORnet meeting, and Health Datapalooza.