Second Opinion Insurance Issues

Posted by concernedadvocate @concernedadvocate, Oct 21 3:26pm

The past two weeks have been an insurance nightmare. Dad's lung cancer oncologist's opinion was no more treatment now that LMD has appeared and said seek a second opinion if you wish. He has Aetna Medicare Advantage HMO. The PCP is wholly unfamiliar with the GAP exception process and their front desk originally tried to just fend us off with a blank referral. The insurance company is also no help. The PCP and insurance both said it can't be done, while the two facilities we chose said it could be. It took me calling the facility we wished to see to get a phone number for the PCP and facility to three-way the insurance together.

Has anyone tried to get second opinions at two out of network facilities? The PCP who was unfamiliar with this to begin with has warned us that the insurance may only approve one second opinion at a time using the gap exception request. Would it help to wait after the first second opinion to apply for the second facility?

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Colleen Young, Connect Director | @colleenyoung | Oct 29 8:16pm

@concernedadvocate, I'm wondering how you managed to resolve the issue. Were you able to get approval to seek a second opinion?

nrocpop | @nrocpop | Oct 30 8:03am

There is a show on Sirius XM called Healthcare Connect (not positive on the name of the show). They know all the ins and outs of these kind of insurance policies. I think that show is on Thursday mornings and you could call in for help.

Lisa, Volunteer Mentor | @lls8000 | Oct 30 1:10pm

I'm sorry to hear that you are dealing with insurance issues, @concernedadvocate. It's difficult enough to navigate lung cancer, let alone being faced with the complexity of the insurance world. He's fortunate to have your help and love.
How is your father feeling? Is he open to seeking a second opinion, and ultimately additional treatment? Was he considered stage IV before the LMD appeared?

steveron | @steveron | Oct 31 6:56pm

My wife had a similar issue in that her insurer, Southern California Kaiser Permanente Medicare Advantage, would not cover out of network pancreatic cancer surgery even though the surgeons would have been better qualified. We did not push as hard as we might have. A year ago at this time I wish we had switched to Original Medicare + Supplement G for 2024, which would have allowed her to see any doctor that takes Medicare. Perhaps you could switch for 2025. Be sure to find an insurance company that doesn't require underwriting. California Blue Shield was such a company for 2024.

You may also consider finding an insurance company now that would provide the coverage you need. You would have to disenroll from your current policy and enroll in the new policy. The Medicare website has more details.

We looked into separate cancer insurance, but no company would issue her a policy with pre-existing cancer.

We also researched buying a stand-alone policy separate and in addition to Medicare. Insurance companies and Medicare reps told us no company would issue such a policy since she was eligible for Medicare, even though we were willing to pay for it.

If insurance insurance issues cannot be resolved, fundraising may be another option, either through GoFundMe, Facebook, or the American Lung Association at https://bealungsaver.funraise.org/lung cancer support group.

Don't take "no" for a final answer. Appeal up the org chart whenever possible.

Best wishes for successful outcome.