At 53, Laura was feeling some abdominal discomfort and went to see her doctor. After an ultrasound and further scanning, her doctor told her that the likely diagnosis was ovarian cancer and referred her to a general surgeon and a medical oncologist at a hospital located in a mid-sized city near her home. This was the same hospital where her mother, who died of breast cancer twenty years ago, had received care.
Laura knew she really wanted to be evaluated and possibly seek treatment at the Cancer Center where her friend was treated and had a good experience, but was nervous to ask her doctor. Laura was also concerned about whether or not her insurance, an HMO, would cover services at the Cancer Center, but she didn’t know how to go about finding out, and she didn’t want to delay treatment.
Laura called the Center for Patient Partnerships and spoke with an advocate who read through Laura’s insurance policy with her and found that she could receive care out-of-network with a referral from her doctor. The advocate encouraged her to ask for a referral, but it was denied. Without the referral, Laura would be liable for the entire bill, possibly tens of thousands of dollars.
Laura and the advocate went back to the insurance policy and read about the process for an expedited grievance to overturn the denial, which included writing a letter giving the reasons for the request along with supporting evidence. With the help of a medical librarian at the medical school library, they were able to pull together some articles comparing the survival differences for ovarian cancer patients operated on by general surgeons vs. board certified gynecologic oncologists. They wrote and submitted a letter requesting referral to the Cancer Center along with the supporting articles. Within 48 hours Laura’s request for referral was granted.
