Utilization Review (UR) for Sarcoma Treatment

Individuals battling sarcoma will undergo countless tests, procedures and treatments over the course of months or years. The goal of utilization review in sarcoma cases is to ensure patients receive the most appropriate care to treat their diagnosis. Insurers use an evidence-based approach during the utilization review process to make sure patients do not receive duplicate or un-proven procedures.

Utilization Review During Sarcoma Cancer Treatments

Doctors use the clinical information and medical literature they have available to prescribe medications and treatments for their patients. Sometimes it is unclear what is the most beneficial course of treatment based on the medical evidence. UR can assist physicians and insurers with plotting the right path especially in complex cases. It enables sarcoma patients to receive the best care possible guided by the evidence based medical literature to avoid inappropriate or unnecessary treatments. When treating Sarcoma new, experimental procedures and drugs are available. There may be a new-targeted therapy or anti-angiogenesis drug for a type of sarcoma, but it may lack sufficient evidence to support its efficacy. It is common for patients to want to try these treatments but question whether their insurance companies will cover it. A UR allows physicians to request approval of a service before it’s given.

Working with the Utilization Review Process

The UR process may seem burdensome with additional paperwork, time and oversight. However, this system ensures appropriate and evidence based treatment for patients. The UR process allows for a physician appeal in the event of a denial. If the request is still non-certified, the patient and physician can ask for an Independent Medical Review (IMR). Through an IMR, physicians working independently from the insurance company review the patient’s case. An unbiased determination can then be made based on the patient’s clinical information, appropriate guidelines, and current medical literature.

“Advanced Medical Reviews has one of the industry’s largest independent physician review panels and is proud to provide high quality and timely utilization peer review and independent medical review services,” states Dr. Charles Carnel, AMR’s Medical Director. “We understand how important it is for insurers, physicians and patients to receive thorough and objective reviews as quickly as possible. Our exclusive database and workflow technology allow our physicians to work efficiently, with all of the information they need at their disposal.”

Assistance for Sarcoma Patients

There is help for sarcoma patients who need guidance through the complicated insurance system and who may need financial assistance for treatments that are not fully covered or not paid for by insurance. If a patient needs help with authorization for a treatment with an insurer, they can contact:

• The Patient Advocate Foundation: PAF helps patients gain authorizations for treatment or appeal denials. They can also assist if there is a billing issue following treatment.
• The National Association of Insurance Commissioners: The NAIC can help patients understand federal and state insurance laws.

Individuals should also request a case manager from their insurance company, giving them one person to speak with every time they call. That case manager will be familiar with the situation and better able to help.

For financial assistance, patients can reach out to:

• Hand in Hand offers assistance for second opinion consultation, including travel expenses and medical costs for the evaluation.
• Childhood Cancer Society helps families dealing with pediatric cancers pay for medical care, travel expenses and living accommodations.
• Kylee’s Dancing Angels enables sarcoma patients to find financial assistance.
• CANCERcare provides patients with professional services and some financial assistance.
• American Cancer Society can help people with their housing, food, travel, phone and other financial needs while someone undergoes treatment.

The Sarcoma Alliance, The Liddy Shriver Sarcoma Initiative and the Cancer Financial Assistance Coalition provide more comprehensive information on financial assistance for families fighting sarcoma or other types of cancer.