Insurance and Clinical Trials

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DianeEE
DianeEE Member Posts: 3
edited June 2014 in Employment, Insurance, and Other Financial Issues

Hello,

I am scheduled to start a Phase II clinical trial this week.  I called my insurance and have gotten conflicting info. as to what they will cover.  The trial will cover all costs relating to giving the medication but will not cover any side effects.  One person at Golden Rule Insurance said that they will cover routine care but would not cover any care relating to side effects.  The last person I talked to said that they would not cover any health claims for me at all while I was on the trial.

I talked to a patient financial conselor at my onc.'s office and she said that she tells clinical trial patients to never talk to their insurance companies before the trial.  Because any claims that are submitted will be coded as a medical procedure, they will be covered.  She said that there is no way for them to know if the service is the result of a clinical trial or not.

I would like to believe the financial counselor.  But, I worry that I'll have some sort of side effect and the insurance won't cover it. 

Does anyone have any experience with what "actually" happens to claims during a clinical trial?  Has anyone had a good or terrible experience with costs during a clinical trial?  My feeling is to just do the trial and fight claims if they are denied.  Or, would it be better to get approval before the trial starts? 

Any thoughts or advice would be appreciated.

Diane in Michigan

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  • lauri
    lauri Member Posts: 267
    edited September 2011

    The knee-jerk response from my Blue Cross plan was "we don't cover ANY clinical trial costs -- they are excluded as "experimental"  Luckily, I was in a big teaching hospital that did LOTS of trials so the trial coordinator called the insurer and they ended up agreeing to cover everything (trial was just checking the effectiveness of having AC and Taxol on weekly versus two-week cycles, so the actual chemos weren't anything new)

    Don't take a "NO" from anyone -- keep bumping up to a supervisor or department head.  Nobody can tell in advance what side effects you will get from ANY chemo, so they'd probably have a hard time denying care for a medical condition.  (But make notes of names, times and substance of all conversations in case you need to "remind" the insurer later.)

    Good luck !

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  • Chickadee
    Chickadee Member Posts: 4,467
    edited September 2011

    Your Oncs financial person should submit a treatment plan and get your treatments pre approved.  They know what codes to give them.  I did a clinical trial and was covered 100% by my insurance.  I didn't call the insurance folks, I left it in the hands of the Onc.s office folks who know how to work the system.

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