When Kate was diagnosed with cervical cancer, her doctors were optimistic.
The right treatment could mean that Kate “could heal and live a long, healthy life.”
But, Kate’s insurance company had other plans. UnitedHealthcare, the largest insurance company in the country, refused to cover her cancer treatment, citing an analysis from the Institute for Clinical and Economic Review.
“I remember literally being in the chemo chair one day on the phone with UnitedHealthcare, fighting them to overturn the rejection, and they wouldn’t,” Kate tells the Boston Globe. “Unfortunately, the insurance company knew it would cost more, and they put the bottom line above me as a patient.”
Kate’s story isn’t unique.
Every day, patients across the country are fighting insurance companies that have denied the treatment recommended by their doctor. And a critical component of the insurance denial process is provided by the Institute for Clinical and Economic Review.
“It’s horrible,” says Dr. Jay Loeffler, chief of radiation oncology at Mass. General, who spends hours battling insurance denials. “We’re losing the battle of getting patients on treatment.”
A private, insurance-backed organization, ICER supersedes the authority of the Food and Drug Administration to conduct its own economic analysis of medical care. Except ICER’s analyses are rigged from the start.
“ICER starts from the premise that a patient living with cancer is worth less than a healthy patient,” explains Terry Wilcox, co-founder and executive director at Patients Rising, a national patient advocacy non-profit that helps patients overcome insurance denials and other barriers to access. “ICER is a threat to women’s health – denying women with cervical cancer the treatment prescribed by their doctor.”
ICER Linchpin in Insurance Denial Process
Here’s how it works: Insurance companies and their allies have provided millions of dollars in funding to support cost-benefit analyses by numbers-crunchers at ICER. Then, when ICER determines a treatment is too expensive, the insurance companies use that report as the basis to deny treatment.
That’s exactly what happened to Kate.
“The first denial of insurance coverage came as a surprise, Weissman was at the hospital already prepping for proton treatment,” the Boston Globe’s Priyanka Dayal McCluskey reports. “Over the next few weeks, Weissman said, she and her doctors appealed the insurer’s decision six times. She and her husband spent countless hours on the phone trying to sway the company. But every time, the answer was no.”
However, UnitedHealthcare picked on the wrong patient. Kate refused to accept the insurance denial, and now, she’s fighting back by filing a class-action lawsuit in Massachusetts.
“I realized how many other patients must have gone through what I went through, and how many other people didn’t have the resources that I did to be able to pay for my treatment,” Weissman says. “I felt a calling to make this my mission.”
The lawsuit will help put pressure on insurance companies to provide patients with the treatment recommended by their doctor. For patients like Kate, that means access to proton radiation, which precisely target tumors and reduces the harmful effects on healthy tissue.
Facing off against UnitedHealthcare, the biggest insurance company in the world, does Kate stand a chance?
“We may not have billions of dollars, but patients have incredible power when we work together and speak with one voice,” says patient advocate Terry Wilcox of Patients Rising.