End of life cancer treatment - insurance questioning medical necessity.

[sjc0816]

This is a long and crazy story so bear with me. 

My FIL passed away almost 2 months ago after a relapse with Lymphoma. He was 76 and it was an extremely stressful last few months of his life....and here's why. 

He was being treated for about 18 months successfully before being hospitalized 8 weeks before he died.  After he was hospitalized, it was determined that the cancer was resistant to treatment and hospice was recommended.  My FIL refused hospice and demanded treatment.  The only treatment remaining to try was a CRAZY high dose chemo that multiple Oncologists strongly urged against.  He demanded it.  He received the chemo for about 5-6 days and then proceeded to die a painfully slow death continually for the next 3-4 weeks refusing hospice.  While at the hospital, they continued giving him TONS of daily meds.....platelets, blood transfusions, TPN (IV nutrition since he stopped eating and drinking), neulasta shots daily, steroids, and on....and on....and on.  His family (my husband and everyone else) urged FIL to stop the madness but he would not hear of giving up the fight even though every doctor said the fight was over.

Finally, when he was semi comatose....my MIL had him transfered to hospice where he died 24 hours later.

Here we are 2 months later and the total hospital bill is around 500K.  He was on my MIL's insurance (she is working) and MIL is convinced that she will not owe a dime.  She has not received a bill....but has received a letter stating that the insurance company is examining the treatments given as they believe many of them were medically unnecessary.  I'm not sure how long this process will take - but DH and I are VERY concerned about her financial situation.  My FIL was 15 years older than MIL and didn't believe in saving.  MIL makes about 40k per year and owns three cars including a large Lexus SUV, Lexus sedan and a 1976 Corvette.  FIL also just purchased a Harley Davidson that we are trying to sell.  She used the majority of her savings to pay for his funeral.  Luckily, she has a JOB and a paid-for house.....but that is all. 

Just curious if anyone has experience with insurance and a major situation like this.  I'm getting the feeling that she is going to be in a devastating situation.....which was our biggest concern when FIL kept demanding to stay in the hospital receving these treatments while he was dying.  Doctors never said that insurance might not pay, etc.....but maybe that's not their problem or concern? 

What could we be looking at here? 

[Trudie]

I would get a copy of the summary plan description for the health plan and hire an attorney.  It all comes back to how that document is written and spells out responsibilities for medical pre-certification and benefits.  Each case is unique, so your time spent here discussing it might be more anxiety-provoking than anything.  An attorney could advise you about any concerns about protecting assets and limiting liability.  Good luck!

[Orvell]

:( I'm very sorry for everything you and your family are going through. I don't have much useful to say beyond that, but I hope someone else will.

My personal experience is that doctors don't think/worry about the money unless you bring it up; they don't know your insurance situation, nor if a procedure or medicine will be covered by your insurance or not - that's 100% between you (general you) and the insurance provider.

Good luck.

[goatmom]

Sorry for your loss.  Wasn't your FIL on medicare?  I wouldn't get too worried yet.  Often the insurance company will try to get out of paying for something by saying it was medically not necessary - the doctor then needs to write why it was necessary.  It is a big game they play to get out of paying for things.   Doctors in general will know when something is considered "experimental" or "off label"  and won't be covered.  But, they ordered the drugs which meant they must have thought they were needed.  Best of luck.

[Orvell]

Sorry for your loss.  Wasn't your FIL on medicare?  I wouldn't get too worried yet.  Often the insurance company will try to get out of paying for something by saying it was medically not necessary - the doctor then needs to write why it was necessary.  It is a big game they play to get out of paying for things.   Doctors in general will know when something is considered "experimental" or "off label"  and won't be covered.  But, they ordered the drugs which meant they must have thought they were needed.  Best of luck.

:( It sounds like this might not be the case. OP says:

Oncologists strongly urged against.  He demanded it.

I think Trudie is right. An attorney can probably help you out a lot here.

[honeybbq]

Well, what you have going for you is that these were prescriptions (essentially) that were ordered by a physician. Usually in oncology, there is a pre-authorization process that happens and makes sure that the insurance co. agrees to pay.

However, upon retrospect, an insurance company may deny the claims, particularly if it is not "routine" or standard of care for a similar person in a similar situation. You can't just demand 'every' treatment and get it because you are noisy; there has to be clinical evidence standards to provide a treatment. 

It sounds like he was treated at a hospital, which usually has better insurance procedures than alternatives (doc in a box, etc). So that's good, too.

If worst comes to worst, it may be practical to hire an attorney and consider bankruptcy. Depending on what state you are in, she might be able to keep a house and a car and just continue on since she doesn't seem to have a lot of assets.

[kite]

76?
Wait on Medicare & MIL's insurance.

She is in a devastating situation: her husband just died.   Help her adjust to her new reality.  But try not to fret about the $500k statement.  My father ran up a similar sized bill for much less time in the hospital. 

She may eventually need an attorney, but not before she gets a bill which says "Pay This Amount."  Sorry for your loss.

[The_path_less_taken]

Sorry for your loss.

Insurance companies make zero sense to me.

But I'd explore 'homesteading' her house. It's an ancient law, that supposedly protects it from being taken for crap like she's going through, under the concept that "you gotta live somewhere".

Good luck.

[AZDude]

Bankruptcy is your friend in this situation. Homes are usually immune from bankruptcy procedures, but the excess cars might end up getting auctioned off.

[Dicey]

...but the excess cars might end up getting auctioned off.

I doubt it. She could always sell them herself (or the OP could do it for her) for a better return.

To the OP: IF the insurance company denies the claim, then consider an attorney and/or bankruptcy. Feels a little like y'all are worrying in advance of a reason to.

So sorry for your loss. My MIL has a will and directive in place from at least a dozen years ago, complete with DNR. The insurance wanted a more current document, but she has full-blown Alzheimer's and is now insisting that anything and everything be done to prolong her life, sigh. Finally they sent someone out for a home visit. End result is that DH and I have been empowered to carry out her original wishes. Sigh.

[Abe]

The cost will likely be much less. The insurance company may not cover if 1) the drugs require pre-approval and this was not obtained (unlikely since tte hospital would get approval to avoid having to eat a lot of the costs if the insurance company doesn't) or 2) the drugs were used off-label (without formal approval from the FDA). This is more a common scenario with chemotherapy for various legitimate reasons. If that were the case you can likely get the hospital to pay for the costs if they didn't tell you ahead of time, as they are required to do so in writing for Medicare patients (and most insured patients). Even then, the costs may be reduced with negotiating with the hospital, especially since it wasn't your mother in law's decision to continue therapy.

Unfortunately this is a common scenario and until we ration essentially futile care, will continue to burden all involved parties.