Independent Medical Review California Department of Insurance

[Abbe]

Hello all,

I am not sure this is the correct path to pursue but I figured after 3 denials it might be worth a shot. The State of California Department of Insurance has a claims service bureu where a consumer can request an Independent medical review. I found forms for the patient and forms to be completed by the physician to request a review. One of the criteria listed in the physician's request is that the treatment is considered Experimental/ Investigational and that the doctor believes
1.)The insured has a terminal medical condition, or a life threatening condition, or a serious debilitating condition.
2.) The insured has a condition that qualifies under one or more of the following.
a. Standard therapies have not been effective in improving the insured's condition.
b. Standard therapies would not be medically appropriate for the insured; or
C. There is no more benificial therapy covered by the policy.

I figured I would try this before seeking legal actions which I am sure would be a long and drawn out process since ERISA has now made it a federal process to sue your insurance company.

I am not aware of other states processes but I would think they are similar.

Here is the link to California's Department of insurance Independent Medical Review application.

http://www.insurance.ca.gov/0100-consumers/0020-health-...ed/0020-imr/#whencan (http://www.insurance.ca.gov/0100-consumers/0020-health-related/0020-imr/#whencan)

I hope this process is a help to someone and I hope I can get some help this way.

Abbe

[LBP]

Don't get your hopes up. I did the "independent" review through the Calif Dept of Ins ...they upheld PacifiCare's denial.

[Julaine]

In August of 05 i went through the review it was a waste of time, they agreed with BC, athough this time since adr is fda approved it could be different.

Julaine

[LBP]

Well, I asked for a review for a 2 level Charite when Charite was approved by FDA and it didn't matter. When I tried to get a second review for a hybrid Charite/fusion they wouldn't look at it...said it was a duplicate request. I ran out of time on my COBRA to argue anything different.

Good luck

[LBP]

Somewhere (I thought on here) is a heads up on how to best use your state insurance dept. Maybe someone else knows the thread. I was thinking it was a post by the insurance warrior but maybe not.

I think they helped put the pressure on my ins company when they tried to cancel my policy but not so helpful in overruling a coverage dispute.

[marilyn michalak]

We need change. In France, the ambulance gives you a ride to the hospital, and they do your laundry there. We just want medical care paid for.
We have to unite. Single claims of injustice are routinely ignored. The insurance industry is wealthy, powerful and corrupt.
We are Americans. It is our job as citizens to get involved, and to effect change.
1) All senators and representatives these days have email addresses. I have mine on file and write a simple message about issues all the time. The more letters they get, the more they pay attention. It takes volume.
2)We deserve and should have health care, even if we got injured at work. It should be simple, and a single payor system might be considered. I personally have three insurance carriers and they all get out of paying. One doctor's office quit taking insurance at all (we do it ourselves) because she was spending so much money paying people to straighten out the insurance mess. And it was questionable whether she would get paid at all or in part.
3) Socialized medicine may not seem appealing to many, but we rank 37 in health care compared to the rest of the world. We Americans could come up with something that would be better than the rest of the world. We have the best medicine here, we just don't get it because of the fraud going on in the insurance industry.
3)We are already using our connections with Oprah and Michael Moore. Whether you like them or not, they are icons, and can help with this issue.
4) ERISA laws hurt the American Worker. They should be done away with, and retroactively if possible. Many disabled people are living on the edge when they purchased insurance through the companies they worked for. Some lose their homes,commit suicide, lose spouses because they have no money coming in.
This web site is a good place to unite. Numbers. Large numbers of people uniting to make a fuss is the only way. Writing representatives, peaceful demonstrations, using connections with celebrities.
Marilyn Michalak
3 level lumbar ADR
Stenum'07
Still suffering from sacroiliac joint dysfunction
Need medical treatments that are not paid for by insurance companies.

[ans]

You never know though. Maybe if you kick-butt (tons of references, personal communications, etc.) and someone's in a good mood you'll get lucky.

I have BCBS and they'll flat out deny an ADR naturally claiming it's "experimental" despite FDA approval. Odd.

[Abbe]

O.K. Thanks for all the replies! I have been working hard on putting this package together. In the middle of sorting everything out paper-wise I contacted "The Insurance Warrior" Laurie Todd the author of the above-mentioned book. She was very helpful and sent me an example of an appeal she had done for another person seeking insurance coverage for ADR Prodisc. She no longer works for individuals but she had sent an example of this Legal & Medical document to me leaving out the names and telling me to plug in my information and edit it to conform to my case. So, that's what I have been doing. Not an easy task since the document she sent me was for someone whom already had an Artificial disc done in 2004 and BCBS covered it and was now seeking coverage for a second disc to be covered by BCBS. Laurie has suggestions of who to send this document to: Medical director of Blue Cross Blue Shield, Director of Managed Care Health Care, State Insurance Commissioner, Dr. who would perform the surgery, Pres. of City Medical Society, Pres. of state Medical Association.

So, I have been busy cutting and pasting and documenting and I currently have 3 different applications for Independent Medical review. I am also scheduled for a test I have never heard of. Instead of an EMG where they stick needles into you and you feel like a voodoo doll I am having a Nerve conduction test done. Has anyone had this test done? How reliable is it? I have heard that EMG tests can give false results.

So, anyway after I get the results and also have another appointment with my Neurologist Dr. I will finish up my epic appeal document and have it sent off. I do not expect that I will get responses quickly so it will be a waiting game.

I also thought of getting in touch with the first doctor who did my Laminectomy, discectomy back in 1992. He is now a lawyer but I am not sure what type of lawyer he is.

Abbe

[spotty14]

If I remember right the nerve conduction test they put a device on your skin over certain nerves and zap the area (it hurts!) and measure something about how the nerves function. Some of the areas they did actually forced my leg to move and sort of twitch with each zap. I had this done the same day as the emg. Lots of fun.

[spotty14]

I've used the appeals process at the California Department of Managed Care to appeal denial of treatment for denials by private insurance HMO's. It wasn't for spine surgery though.

[CindyLou]

I recall the nerve test just about the same as spotty14. My leg really jerked too. Painful, but not too intense. Nothing like a discogram, so I wouldn't worry about it much.

[Abbe]

Appeal book is done and bound! It cost me a small fortune to have printed up, tabs put in, and bound. I had 6 copies made and I have sent 4 of them out already. I sent one to the state for actually 3 requests:
1. Independent Medical Review
2. Physician Certification Experimental/Investigational Denials (Signed By Dr. Delamarter)
3.Request for assistance

My "Book" has approx. 140 pages and 10 tabbed areas. This is my last ditch effort and I feel like I have completed my masters thesis in putting together this book.

Laurie Todd and "Harrison" have been very helpful in their suggestions. It really helped me pull all of the research I had been doing together and organize it. All I can do now is wait for the sh.... to hit the fan and we will see what happens if anything....

Abbe

[marilyn michalak]

We are all being denied healthcare, or the payment of by insurance carriers. It will take more than one person with immaculately bound records to break "the system" , I fear. Having been through the workman's comp mess, and the Erisa nightmare, I can honestly say that the insurance companies all use the same "techniques" to wear us down, wear us out, and end the end, they "win" because we are sick and they have more money. The most effective tool they have is to "drown" us in paperwork. And then they send you to "Independent Medical Exams" of their own. With their own doctors. They are not independent. They are paid assasins. Then come the films. If you can get out and actually take a walk one day, they will be there to film it. They will say, "look there's some one just fine, taking a walk". One good picture is all they need, in today's climate, to ruin your credibility. A judge will easily write it off. Just one picture. Your life may be filled with pain, but they will deny your claim and your credibility with the most innocent sunny day's walk, or stumble. Be aware that that picture is the next step. The insurance industry routinely hires private detectives to do the dirty work of filming. It happens as a matter of business, and be careful what you do.
Marilyn Michalak
Back Hell 8 years and going

[marilyn michalak]

By the way, I have a copy of the films used against me. This is someone who is sick and stumbling around , trying to walk. I have three copies if anyone wants one.
You are in the system, be careful.
Marilyn Michalak
Back Hell

[Abbe]

HI again,
Well, I got a call from the California Department of Insurance and they told me our insurance would not be covered by them. The woman told me that Motion Picture is a self funded Insurance and that she could foward my book I put together to the Department of labor. Then a few days later I got a call from a very nice lady from the department of labor anf she told me that there was nothing they could do but ask Motion Picture for all the details from my denials and that different people were supposed to do each review and ask for all the material they used for their decision. I had asked for the information they based they last decision on and all they sent me was a cryptic email from Motion Picture medical director and someone at Blue Shiield. Blue Shield is our hospitalization through Motion Picture Health Plan. It did not look like there was any review just Motion Picture medical director finding out from Blue Shield that they did not want to cover it. In the mean time I got the new "Plan" from Motion Picture and now as of July 07' ADR is mentioned specifically as not being covered under this plan. I guess I am S--- out of luck! The only this I can do is sue in Federal court, or find a way to pay out of pocket, go ahead with the fusions at L5-S1 & L4-L5 leave L3-L4 alone or do nothing and live the way I am now...... sometimes not so bad. I am so confused and don't know what to do. http://adrsupport.org/groupee_common/emoticons/icon_confused.gif

Abbe

[ZorroSF]

I think the real question is CAN you afford to pay out of pocket and pursue that insurance institution 6 months post-op.

it's going to be a long and rough ride no matter what you decide. Another question is whether your insurance will pay the hospital bill. If you can get pre approval for the hospital bill then you'll have no problem getting the surgery. Of course if you use delamarter then you're paying the whole doctor bill out of pocket first and he will charge your insurance later. He can charge an outragous amount, so be careful. There are plenty of good surgeons here in LA.

On the other ahnd, if you can afford Delamarter to be your surgeon, then you can afford to go to germany.

Abbe;

Sorry about your insurance woes. Not that this will make you feel better but I got denied by UHC. I had to call to find out if I was denied. Today, I find out from my doctor's office that the reviewing doctor from UHC agrees it is the best procedure for me but since my company is self-insured he cannot override the program. His message told my doctor that he did not need to call back because he was just calling because he was required to do so. My doctor did call him back but I have no idea what was said.

In addition to this my husband's policy has a clause that states they will pay for an unproven procedure if it is less expensive than another approved procedure and that it will not set precedence. His boss is a chicken _____ and will not go against the company so he will not approve the override.

That leaves with a two level fusion or preparing for a trip to Germany. Right now I am leaning towards the fusion because I am tired of dealing with the ugliness of insurance. I need to focus on getting my life back.

Best of luck in finding relief.