Choose the Best Insurance Before, Not After, a Critical Diagnosis

Insurance problems are never easy to handle but this has been a particularly difficult month for many of my patients due to insurance issues. One patient required urgent surgery for removal and biopsy of a mass; time was of the essence. The surgeon was able to find room in the schedule on a Friday at 3:00pm. All was in place. Thursday evening at 8:00pm, the patient was informed the surgery was not authorized at that hospital and would need to be performed at one of their contracted hospitals at a later date. 

Instead of an evening with family in preparation for surgery that would most likely result in a cancer diagnosis, a different stress entered the picture. The patient had no choice but to set aside the hope for a quick surgery, and begin a battle with authorities in the morning. Early Friday morning, the patient and surgeon were on the phone with insurance making their case to keep the scheduled surgery for that day. At 10:00am they did finally receive the authorization to maintain the original surgical schedule with the chosen hospital and surgeon. Cancer was indeed found. 

These battles are all too common.

Last year I lost a Glioblastoma patient. His was an extremely aggressive cancer; moving quickly to his untimely death just 5 months after diagnosis. Once the ER scans revealed a brain mass, patient was discharged home to await the additional test of an MRI, which would reveal more about the cancer. His insurance took 8 full days to authorize the MRI. This may not seem like a long period of time but this man declined rapidly in just 14 days; from walking into the ER with an odd weakness in his arm and gait, to loss of mobility in just 2 weeks. To this day I wonder if that 8 day wait could have made a difference in his prognosis if treatment could have been started before his rapid decline. 

Mark Mathias of Mathias Benefits Group, an expert in the field of health insurance, is committed to helping us navigate and prepare for this complicated issue. In reading through his recommendations, one can certainly appreciate how time-consuming and frustrating health insurance can be when we are faced with critical issues. Choosing the right insurance before that time comes matters, and Mark explains why. His words below:


Choosing the Best Medical Coverage when you have Cancer

Most cancer patients don’t really learn about their medical benefits until they are diagnosed with a life threatening illness like cancer. That’s “par for the course”: most of us don’t learn about our auto insurance coverage until we have an accident. Hopefully, you made good choices that provided needed coverage before you needed it.

These are some quick thoughts about insurance coverage in general:

1) Understand the tradeoffs between monthly premiums and deductibles/copays – low monthly premiums (HMO or CDHP vs. PPO) usually have very high deductibles and copays in relative terms. You need to do the math to understand that low up-front costs might have high back end costs. Every plan is different so get out your calculator.

2) Dial in on your pharmacy plan – make sure each of your medications is covered, understand the most cost effective way to get your medications delivered – retail v mail order. Understand that major vendors (Target and Costco) are less expensive than the retail pharmacies.

3) See if your expensive medications offer a patient assistance program – many manufacturers offer discount programs to keep you buying their medications. Work the system to your favor.

4) Be sure that your doctor and preferred hospitals are in network for your plan – you need to present your actual plan numbers to be certain. Don’t accept the doctor’s office statement, “why, yes. Dr. Smith takes Anthem.” She may take some Anthem plans, but not all. You need to understand the network limitations of your plans – the providers don’t care until they bill you. Do not rely on general statements.

5) Think about your medical future as it applies to your medical benefits and plan ahead. You may need access to research centers in other parts of the country. You may need access to different physicians for second opinions. Find out now.

6) Check on the mental health benefits of your medical plan – no, serious medical illness doesn’t make you crazy. It can tax your mental health and the health of your family. Understand that there are mental health resources to use. So, use them.

7) Be sure that your family keeps up on their health and well-being. They need to carve out time to assure that they are “tan, fit and Rested.”


These are the basics. Just like you are fighting back in your illness, you need to fightback and assure that you are getting the most possible from your medical benefits plan.


Mark Mathias