"The Insurance Warrior," Laurie Todd

[Harrison]

The Insurance Intelligencer
9/2/11

The Five Wise Men

Ever called your insurance company? Call six different people, and you will get six different answers. They will tell you that they never heard of whatever you are asking for, the person that you need to speak to is on vacation, and they don't know the name of their supervisor.

People -- especially people who are ill and actually need something -- become discouraged and exhausted by talking to their insurance companies on the phone. Finally, they give up.

The only people whom we are allowed to talk to at insurance companies are people who know nothing, and who are not decision-makers. Their job is to get rid of us by saying, "Just wait for our letter."

Why then should we ever call the insurance company? To write down all of the ridiculous things that they say -- so that we can put them in our appeal.

The Runaround Story

A winning appeal is not an attempt to prove to the insurance company that you really need a treatment, that the treatment is approved by the FDA, or that this is the only effective treatment for your disease. A winning appeal needs to be so unsettling and unnerving to the insurance company that they want to get rid of it as quickly and completely as possible. The only way to make sure that nobody else ever sees this cringe-worthy document is to immediately pay for your treatment.

You will offer a mountain of scientific evidence for your treatment. However, it is the ridiculous, non-sensical, unreasonable, arbitrrary, deceptive actions of the insurance company -- revealed by you in the most embarrassing manner -- that will win your appeal.

The five nuts from Worcester

Deb has a "Blue HMO" plan with Blue Cross Blue Shield of Massachusetts. In other words, she can only see doctors in the state of Massachusetts who happen to be under contract to her HMO. What happens if she needs a complex and difficult cancer surgery -- and no surgeon in Massachusetts who is a provider for HMO Blue can perform it?

What happens is that BC/BS of Massachusetts sends Deb a letter, informing her that the out-of-network surgery with Dr. Sardi has been denied, because, "the requested service is available in-network." BC/BS of Massachusetts has no idea if this treatment is available in their HMO network or not. They simply say, "it is available in-network" ... and let you exhaust yourself proving them wrong.

I instructed Deb to call BC/BS of Massachusetts, ask for the list of in-network surgeons -- and to write down everything they said. What I wanted was a cringe-worthy story. This is exactly how it looked in Deb's appeal:

1. What is that treatment?

On 8/23/11, I spoke to Tina at BC/BS member services. I explained that I have a recurrence of appendix cancer with liver metastasis, I need cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, and the BC/BS denial letter states that "the requested service is available in-network." I then asked for a list of the in-network surgeons who offer this treatment.

Tina asked, "What is that treatment?" She then placed me on hold for twenty minutes. When she returned, she gave me the address of the appeals department, and suggested that I write an appeal.


2. Cut off

On 8/24/ll, I called and spoke with Shayna Thompson. Once again, I explained my condition and the requested treatment, and asked for in-network providers who could perform it.

Shayna put me on hold. I waited on the line for twenty minutes, at which time the call was disconnected.


3. "What is it that you have?"

Later on 8/24/11, I spoke with John in member services. I explained my condtion, told him that the BC/BS letter promised that I would find in-network providers who offer cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. John replied with a question, "What is it that you have?"


4. "You have to choose from the following categories ..."

John asked, "What kind of surgeon do you want?" I replied, "How about a surgical oncologist who specializes in gastrointestinal malignancies, and who performs the requested service?"

John replied, "You have to choose one of our categories. We have hand surgeons, orthopedic surgeons, plastic surgeons, thoracic surgeons, vascular surgeons, and general surgeons." I asked, "Do you mean to tell me that you can't narrow it down any more than that?" "No, that's all we have," John replied.


5. The list of five

I said, "Well, since I don't need a hand surgeon, I suppose that we will have to go with a general surgeon."

John gave me the names of five surgeons. They were all at the same address in Worcester: Drs. Timothy Emhoff, Bruce Simon, Janice Lalikos, Demetrious Litwin, and John Kelly.

Dr. Timothy Emhoff is a pediatric surgeon.
Dr. Bruce Simon is a chest surgeon.
Dr. Janice Lalikos is a craniofacial surgeon.

6. "We don't do cancer."

Drs. Litwin and Kelly are both at UMass Endosurgery. Cytoreductive surgery is not an endoscopic procedure. However, I performed my due diligence, and called their office.

I asked, "Do you offer cytoreductive surgery and hyperthermic intraperitoneal chemotherapy?" The nurse replied, "Honey, you need a urologist." When I asked why I would need a urologist, she said, "We don't do cancer."

I asked, "Can you refer me to anyone who does this treatment?" The nurse replied, "You need to talk to your primary care physician, and she can tell you where to go."

Apparently, my requested treatment is not as available as the BC/BS letter might lead one to believe.

At the end of our conversation, I said to John at member services, "I thought that you would give me a list of credible in-network people who actually do this treatment." John replied, "I can't help you find any doctors. You need to look to your primary care physician for guidance; she will be able to find a doctor for you.

My primary care physician -- Dr. Mary Smith* -- has guided and referred me to Dr. Armando Sardi in Baltimore. (See Dr. Smith's referral letter, page xx.)

******

Imagine the Vice President of Health Care Services at BC/BS of Massachusetts reading this rendition about the Five Wise Men of Worcester. He knows that the president of BC/BS of Massachusetts is also reading it, as is the chairman of the board of directors. What is his first thought? I need to get rid of this, so that nobody else sees it. What is the fastest way to get rid of it? To approve it.

It is time to harness your Runaround Story for good, and to use it in your appeal!

Of course, the Runaround Story was but one persuasive section of a 43-page document. I faxed and emailed the appeal on Sunday night ... and we won on Tuesday morning.

Deb will be on her way to Baltimore for her lifesaving surgery next week.

Peaceful Insurance Warrior-ing,

Laurie Todd
health insurance help

[Harrison]

The Insurance Intelligencer
10/30/11

Sharlene hits a home run

People often ask, "Which insurance company is the worst?" The diplomatic answer? They are all equally bad. The true answer? Anthem Blue Cross Blue Shield of Virginia.

I lost to Anthem BC/BS of Virginia two years ago. Just when it looked like I was going to lose to them again, my helpee did something that I would never advise anyone to do -- and saved the day.

A bitter loss

In 2009, I fought Anthem BC/BS of Virginia for the first time. I soon learned that I was up against a mighty foe. When I faxed the appeal to the executives at Anthem, none of the half-dozen fax numbers worked. That has never happened before or since.

I did everything that I could think of, and I never got the slightest reaction out of Anthem.

My helpee in this case was Buck -- a true Southern gentleman. He had late-stage colon cancer, and he needed expert surgery. It was a bitter loss.

I swore that I would never lose to any Anthem BC/BS company ever again. Over the next two years, I fought Anthem BC/BS of California and won -- twice. I fought Anthem BC/BS of Connecticut twice, and won both times. All the while looking over my shoulder, watching for my nemesis.

Last week Anthem BC/BS of Virgiinia came a-knockin'.

I had one day to write the appeal, and one day to win it. With a case like this, I wished for a helpee with personality of a pit bull. I got Sharlene. She was as sweet as could be. However, she was no pit bull. Or so I thought ...

Sharlene hits a home run

Suddenly, things started moving. The door was cracking open, Anthem was finally answering calls ... they were getting ready to do business.

I called Sharlene, "What did you do?"

Sharlene said, "I was sitting at my kitchen table, worrying about the appeal. Among the stacks of papers, I noticed a letter from my Congressman. The letter said, 'If there is anything that I can do for you, please call.' So I called my congressman."

I have never advised calling your congressman, when treatment is denied. Usually, politicians couldn't care less about our medical treatments, and insurance companies couldn't care less what politicians have to say. However -- against all odds -- Sharlene made it work.

It so happened that the congressman was running for re-election -- which made him a little more susceptible to a media-worthy story like this. Plus, he didn't have to do any research. Sharlene simply faxed the appeal, and gave him the names and phone numbers to call the executives and Anthem BC/BS.

Sharlene said exactly the right words, in exactly the right way. The congresssman jumped all over this case, and spent the rest of the day on the phone with the insurance company.

At 5:02 p.m. on Friday, Anthem BC/BS of Virginia finally -- and very reluctantly -- approved the surgery, and signed the single-case contract with Dr. Sugarbaker's office. Sharlene had her surgery on Tuesday. She is doing very well.

I love it when my helpees rise magnificently to the occasion. And I love it when a case is won in a new, unexpected way that I could never have imagined.

This one's for you, Buck.

Happy and peaceful Insurance Warrior-ing,

Laurie Todd
health insurance help

[MeggieLynn]

A good example of perfect timing, luck - and knowing when to jump in and advocate for yourself!! Great story.

[Harrison]

The Insurance Intelligencer
1/10/12

Healthcare justice for all ... it begins in California

Meeting Oliver

On December 27, my best holiday present arrived. I got to meet Oliver.

Oliver and his family were in the Seattle area, visiting his grandparents for Christmas. We met for breakfast at a pancake house in my neighborhood.

Oliver came running up to me in the parking lot. He asked, "Did you help me get my surgery?" "Yes," I replied, "I wrote a big long letter, and helped you to get your surgery." Oliver threw his arms around my neck, saying, "Thank you, thank you."

Truly, it does not get any better than this.

HIAA 2012: Healthcare justice for all

Oliver was born with craniosynostosis -- a condition where one or more of the sutures of the skull fuse prematurely. In order to fix craniosynostosis, the skull needs to be dismantled, reshaped, and put back together. This is an art and a science -- with the surgeon correcting any defects, and leaving just enough "leeway" for future growth.

Oliver needed to get to Dr. Fearon in Dallas, Texas. Dr. Fearon has performed hundreds of these surgeries for craniosynostosis. He hasfollowed his little patients for eleven years, developed new procedures to make the surgery safer and more effective, and documented his outcomes in thirty-four scientific articles.

Anthem's position? We have three local plastic surgeons who are in-network for Anthem. We don't care what their qualifications are, and we don't care if this is the first surgery they ever performed for craniosynostosis. If they have an M.D. after their name, and they are bound by contract to Anthem ... that is where you will go.

If it were your child -- and his skull, brain, vision and physical appearance were at stake -- would that be good enough for you? Would you accept "Dr. Nobody" because the insurance company said so? You would have to accept it -- unless you happened to find me, and I wrote, fought, and won your appeal.

As it stands now, insurers have ultimate power over what medical treatments we are allowed to have, who gives those treatments, how much they pay for them, and when they pay.

What are we going to do about this? How can we hold health insurers accountable for their decisions? What can we do so that families like Oliver's do not have to fight the same fight again and again?

As of today, there is an answer: the Health Insurer Accountability Act of 2012 (HIAA).

What is HIAA, and what will it do?

• You need a massively expensive surgery/drug/treatment. You had no idea that it would not be covered; you are devastated. HIAA will require policies to be written in language that is clear to people who buy and rely on them. You will have an absolute right to know what you are getting.

• Your insurer just raised your premiums by 35%. There is no limit to how much they can raise them. You can't afford insurance anymore. When insurers apply for a rate increase, HIAA will require those submissions to be under oath and penalty of perjury. Only if the rates are proven to be justified and based on accurate data will they be approved.

• Your doctor tells you that there is only one surgery/drug/treatment that can save your child's life. The insurance company denies it. HIAA will make insurers directly accountable for any harm caused by their decisions.

• The insurer approved your surgery/treatment. It is one year later. Neither the medical providers nor the hospital have been paid; they are now sending the bills to you. The bills are in excess of $100,000.

HIAA will require health insurers to pay covered claims promptly.HIAA will do all this, and much more ...

Healthcare justice for all

You can do something to end the divine rights of insurance companies right now. If this bill gets 504,760 signatures by May 1, gets on the ballot in November 2012, and passes -- it will affect how health insurers do business throughout the United States.

I do not live in California. However, this is my fight. I have dedicated my life to making insurers do the right thing, practice evidence-based medicine, and pay for the lifesaving treatments that people need. This bill will multiply my victories a thousandfold -- a veritable tsunami of good medical care.

The Health Insurer Accountability Act (HIAA) has been accepted by the Attorney General of California. As of today, 504,760 signatures are needed by 5/1/12 in order to put HIAA on the ballot in November.

You can make this happen, starting today. Go directly to the website: Health Insurer Accountability Act of 2012 | Healthcare Justice for All

On the website, you can ...

• See a brand-new video of my story on the home page.
• Read the bill.
• Download a petition, collect as many signatures as you wish, and be part of the solution.
• Donate for the administrative costs associated with this massive effort.
• Share your insurance story.
• Volunteer your skills, time, contacts, or ideas.

Do you know anyone in California? Forward this message to them. They are the ones who can get the signatures, get this measure on the ballot, and vote for HIAA in November.

Do you know anyone in the United States? Forward this message to them. California is the largest market for health insurance in the United States. When this bill becomes law in California, it will transform the way insurers do business in your state, in my state -- in every state in the U.S.

If you want to chat, ask questions, or interact, there is a Facebook group: HIAA 2012.

All of the information is on the website. You can download a petition, gather signatures, share your story -- and become part of the solution today.

Peaceful Insurance Warrior-ing,

Laurie Todd
health insurance help

[laid up doc]

i think that those things all make sense, however this one will be very hard to enforce:

"Your doctor tells you that there is only one surgery/drug/treatment that can save your child's life. The insurance company denies it. HIAA will make insurers directly accountable for any harm caused by their decisions."

there are so many conditions for which some docs think there is only one answer, and others would offer options... there are some really bad docs out there who will say something is the only option b/c it makes them $$... i haven't read through the whole bill, but that's a really tough argument to make in a lot of cases.

[Harrison]

The Insurance Intelligencer
3/29/12

Samantha's story

When mom helpees are fighting for their children ... they trust me immediately, jump into my lifeboat without question, and row like crazy. It's a beautiful thing.

The art of waiting

In January I received an email from Lisa in California. Her 14-year-old daughter needed brain surgery.

I thought that this might be a case for me -- so I called Lisa. What I heard was unilike the cancer stories which routinely come across my desk. This was a story of nine years of Big Trouble. It was a story which would both me, bedevil me, and wear on me. However, what drew me to this story was the emotional resilience of one mom -- who had been moving heaven and earth for nine years to make things better for her daughter.

Samantha was diagnosed with severe Tourette syndrome at age six. This means incontrollable, loud, socially embarrassing, exhausting, repetitive vocal and physical behaviors. On and off all day, every day ... for nine years. Tics so violent that they rob her of friends, of school, of a social life. Tics that injure her to the point of broken bones.

I dedicated an entire page in the appeal to the list of medications that this child has been on over the years -- none of which have been effective longterm:

1. Abilify
2. Klonopin
3. Lorezapam
4. Diazepam
5. Guanfacine
6. Topamax
7. Risperdal
8. Orap
9. Tetrabenazine
10. Haldol
11. Botox
12. Prozac
13. Wellbutrin
14. Zoloft
15. Strattera
16. Gabapentin
17. Vicodin
18. Oxydodone
19. Oxycontin
20. Dilaudid
21. Roxicet
22. Tramadol
23. Prednisone
24. Lododerm
25. Hydrocodone
26. Amrix
27. Tizanidine
28. Hydromorphone

Hundreds of visits over the years to psychologists, psychiatrists, neurologists. Repeated hospitalizations for physical injuries.

The heart of an appeal is the Bad Medical Story. I am used to the Bad Medical Stories of cancer patients -- I had one myself, seven years ago. But this ... so very long, so very hard. This story was an Iron Man triathalon. It was a heavy story to write, much less to live.

Deep brain stimulation has been tried and tested for severe Tourette's. It can work -- when nothing else works. Lisa fought for a year to find a neurosurgeon who would perform this surgery on a 14-year-old. It is routinely done for intractable Tourette's in Europe, but here in the U.S. it is more of a challenge. When she finally found the ideal surgeon -- Dr. Philip Starr at UCSF -- Anthem Blue Cross of California denied it.

I took this case for two reasons. First, this family deserved a break as much as any family that I have ever encountered. Second ... I was moved by mom Lisa. She had been through so much She had found a way to not only fight like a mama lion for nine years ... but to keep it light, keep a sense of humor, keep a family surviving and thriving.

We talked in January. Surgery was scheduled for April 7. I'm sure that Lisa thought that we would immediately start "fighting the insurance company."

I said, "Send me all of the info -- the denial letter, the Bad Medical Story, the proper referral letter from your in-network doctor. I will build a file of the scientific articles, and I will read them. However, we won't be sending this appeal until ten days before the surgery. Anthem would love to have three months to fool around with this case ... but I am not going to allow that. Speed is a strategy."

Lisa trusted me. For the next two-and-a-half months ... we talked, and we waited.

All out warfare

I carefully craft my Addressee List of fourteen high-level decision-makers -- both inside and outside of the insurance company. On Sunday nights, I fax and email the appeal document to all of them.

After I send the appeal -- we do sit around waiting helplessly for the insurance company to have their way with us. No! At 10:00 a.m. on Monday, we begin the Telephone Attack. This is not like calling customer service. I have dug up phone numbers for CEOs, vice presidents, and chief medical officers. I tell my helpee who to call, what to say, what not to say. They report back to me, and I tell them what to say next. The purpose of all this is to keep the pressure on, keep control, and push the appeal through as fast as possible.

These battles are not about clinical appropriateness, and they are not about money. They are about control. An insurance company will fight me tooth and nail to deny a treatment with a mountain of scientific evidence to support it -- which would cost a fraction of the totally unproven treatment which they routinely pay for. It's about control.

My 40-page blockbuster document wrests back control for a few days; the Telephone Attack keeps that control going -- just until they decide to pay for it.

The appeal on their desks first-thing Monday morning. It needs to be approved and wrapped up by Friday. No weekend, no break in the action.

The longer an insurer has to chew on a case, the more ways they will find to deny it.

Speed is a strategy.

Victory is ours

I had Lisa working the phone constantly for two days -- with me coaching, sending additional frosty emails where needed. Strategizing, digging up more phone numbers, calling again.

The surgery was approved at 4:00 p.m. on Tuesday.

This is the story a sweet girl and a lion-of-courage mom who fought against all odds for nine years. The story became mine for two months, we won a great victory, and we shared a moment of pure joy.

It does not get any better than this.

Peaceful Insurance Warrior-ing,

Laurie Todd
health insurance help

P.S. Five thrilling stories have gone by since I wrote my last newsletter; I don't have time to write about them all. Most of the exciting play-by-play happens on my Facebook page: "Laurie Johnson Todd." Come over and join the action!