The Insurance Warrior (Read-only topic) [Archive]

Harrison

09-25-2007, 05:07 PM

The Insurance Intelligencer
9/24/07

UPCOMING ENGAGEMENTS IN THE SEATTLE AREA

This coming week ... Issaquah Library, September 25, 7:00 p.m.
Discover U Seminar, October 17, 6:30 p.m.

**** NEW PODCAST ON MY WEBSITE ****

Do you know a group or organization that needs to hear the I.W. story?

PPO Pitfalls

Or should I say “pratfalls”?

The majority of insured people these days belong to PPO-type organizations. When I ask them what “PPO” means, they say, “It means that I get to go wherever I want for medical treatment.”

These PPOs are often sold on the basis of choice. They are even named with this “enhanced choice” marketing in mind: First Choice, Best Choice, Acme Freedom Insurance.

PPO – what choice do you have?

Not so fast. This type of organization is not so different from any other type of insurance set-up. It involves a group of medical providers who are contracted with the insurer. In other words, these providers have a contractual relationship with the insurance company, which obligates them to accept whatever fee the insurer sets for their services.

Here’s where the choice comes in. In the HMO world, the Primary Care Physician is the gatekeeper—the person in charge of controlling access to services. If you had a persistent bladder infection, and wanted to see a urologist, you had to first sell your request to your Primary Care Physician.

Many years ago, I belonged to an HMO in California, and I encountered just such a situation. After nine months of suffering with a bladder infection, and begging and pleading to be referred to a urologist, I decided to change my tactics (I was already a budding Insurance Warrior). “OK,” I said to the immovable PCP, “How about sending me to a psychiatrist? This infection is driving me crazy.”

He sent me to the psychiatrist, who had no problem sending me to a urologist. Finally, I got the right medication, and the nine-month suffering was over.

In the PPO world, you are allowed to send yourself to a specialist, without going through the Primary Care Physician ... as long as they are within the group that is contracted with the insurer.

Is it as simple as that? Do you simply make an appointment? Not necessarily.

The Pre-Authorization Review

A near-universal feature of PPOs is the “pre-authorization requirement.” Before you go anywhere—in or out of the network—you may be required to request the treatment, and get your pre-authorization. At the HMO, you are required to visit your PCP, and debate with him in person. At least you are arguing with a doctor. With this pre-authorization process, your request drops into the same shadowy no-man’s-land where appeals go.

We recently had a request for out-of-network treatment denied. The next step was a “peer-to-peer” review. Sounds like they find a doctor who is knowledgeable about the treatment—a true peer of your expert—and he renders an opinion on whether your really need it, yes?

The treatment was a chemoembolization procedure, which is performed by a medical oncologist specializing in inoperable liver tumors. The insurance doctor who denied the request was a recently graduated family practice physician, with no experience in oncology. Sort of like the doctor working for the auto insurer, whose job it is to tell you that you didn’t get injured.

If they deny your request, you will have to write an appeal. Sounds like less choice to me, not more choice.

Going out of the network

You have an “out-of network benefit,” yes? This means that you can go to any specialist anywhere, right?

So not so. First, you will have to go through an even more draconian “pre-authorization review.” I guarantee you, if you request an expensive out-of-network treatment, it will be denied every time. Your insurer will state that they are not going to pay because the treatment which you have requested is “experimental,” “investigational,” or “not medically necessary.”

How you overcome these objections is another newsletter. Suffice it to say that the insurer isn’t going to make it easy for you.

Let’s say that, by some miracle, your insurer says, “Sure, we’ll pay for it. Go wherever you want for your treatment.”

Before you go anywhere, you had better count up your total net worth. Your out-of-network benefit is an illusion of choice, all smoke and mirrors. There are staggering financial disincentives, should you need to seek treatment from a doctor who is not contracted with the insurer:

• Higher deductible. Your out-of-network benefit could be subject to a separate deductible, or a deductible that is thousands of dollars higher than the one that applies within the network.
• Higher out-of-pocket. You could be required to pay out thousands more, before the insurer starts to pay.
• Separate cap. Your out-of-network benefit may actually have a cap on it, separate from your lifetime maximum. “Cap” means that that is all they will pay, ever.
• They only pay 50%-70% of charges that they deem “reasonable and customary.”

Let’s say that your cancer surgery plus hospitalization will cost $200,000 (a cheap date, in the world of cancer cures). First, you pay your special out-of-network deductible for tests and office visits relating to the surgery of $1,500. Then, you pay an assortment of co-pays prior to the surgery to the tune of $400.
Finally, when you get through the surgery, your insurer only pays 60%. Not 60% of the $200,000 which was billed, mind you, but 60% of what THE INSURER DEEMS TO BE REASONABLE AND CUSTOMARY, which could be 60% of anything. Just for the sake of argument, let’s say that they decide to pay 60% of $90,000, or $54,000.

Because your out-of-network surgeon is not contracted with the insurer, he is perfectly within his rights to balance-bill you for whatever the insurer doesn’t pay.

You are recovering from your surgery, and you start receiving bills which reach a total of $147,900. Of course, if they have a low cap on the out-of-network thing, you might be paying even more than that.

Some choice, eh?

If you have a PPO, and you need expensive treatment out-of-network, forget that you have any out-of-network benefit at all. Treat the insurer’s offer to pay as a denial, write a blockbuster appeal, and make them pay it all. By that I mean “90% of billed charges, with no patient responsibility.”

Good Insurance Warrior-ing,

Laurie Todd

Harrison

10-27-2007, 04:08 PM

Ask the Insurance Warrior
10/21/97

The Insurance Warrior Speaks!
Listen to my podcast at www.theinsurancewarrior.com (http://www.theinsurancewarrior.com)
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Q: What is an independent review? Am I entitled to one? Does my insurer have to abide by their decision?

A: The independent review holds several pitfalls for us. However, there are ways to turn this process to our advantage.

Let's say that you have requested a treatment (surgery/medication). Your insurer has denied your request, using one of the three all-purpose objections of health insurers: Experimental, Not Medically Necessary, or Out-of-Network.

Where the independent review comes in depends on the rules set forth by your insurer. You may get such a review after one denial, after two denials, or when all appeals have been exhausted.

Remember, each state has its own body of laws concerning insurance. If you are involved in any type of denial or dispute with your health insurer, it behooves you to find out what kind of protections exist for you under state law. Some states have a "Patients' Bill of Rights" that can be used to nudge your insurer into action. Why not call your Insurance Commissioner and find out?

Let's see how the independent review process plays out in real life, so that you can make sure that this "review" is not just a rubber stamp on the insurance company's denial.

What is an independent review?

It is supposed to be a review conducted by an "Independent Review Organization (IRO)." This IRO is accredited by your state, and is supposed to have no affiliation with your health insurer.

If your case is under "independent" review, you are entitled to know the name of the reviewer. Then, run like the wind to your computer, and Google him. If you discover that he works for your insurance company ... you suddenly have a very intimidating and embarrassing piece of information to use as leverage.

Am I entitled to an independent review?

Depends on your state's law, and the provisions of your insurance policy. Most states do call for an independent review, after all appeals have been exhausted. Be sure to call your state's Insurance Commissioner and find out.

Does the Insurer have to abide by the decision of the independent reviewer?

NOT NECESSARILY. What, you say? You are entitled to a review, and your insurer is entitled to ignore it? It depends on the insurance regulations in your state. We have had denial of care cases that went all the way to a third denial. Then, the independent review came to pass. The reviewer ruled that the insurer needed to pay for the treatment, which should be considered standard of care for this disease. Guess what? The insurer ignored the reviewer's opinion, and denied again.

If the independent reviewer decides that the insurer needs to pay, and state law requires the insurer to abide by the reviewer's decision, then they have to pay, right?

WRONG ... if you belong to a group plan. Individual policy, they would have to pay. In the case of a group plan, federal law trumps state law. The insurer denies. The reviewer tells them to pay. The state tells them that they have to act according to the reviewer's decision. If the insurer still doesn't want to pay, they simply kick the case up to ERISA, the federal agency that is concerned with pensions and benefits.

If you belong to a self-funded plan, by the way, neither your insurer, nor your employer, is subject to state insurance regulations. Because, under the self-funded set-up, the insurer becomes a “third-party administrator.” The insurer is not an insurer anymore, and they are not subject to state insurance regulations. And your employer -- who has ultimate say on whether your treatment gets funded – is not an insurance company either, nor are they subject to state insurance law. ERISA is your only recourse.

Have I told you lately to run, run like the wind from self-funded plans?

If you are suffering from cancer, just try appealing to the federal government. The ERISA appeal period is eighteen months -- at best. If your insurer starts talking about sending your case to ERISA, and you call them to explore your options, they will say, "Get a lawyer."

My advice? Do not look to any independent review process to save your life. Write a blockbuster appeal as outlined in my book, and take charge of the process yourself. Prove to the insurer with facts that ...

o Your case has been mismanaged in the most malpractice-worthy way.
o The treatment that they are proposing will lead to an expensive, malpractice-worthy outcome.
o The treatment that you are requesting is tried/proven/studied, and most likely to produce a good oucome.
o Precedent. Hello. They have already paid for this "experimental" treatment three dozen times.
o The treatment that YOU propose will cost less than the treatment that THEY propose.

Then, dig up a successful class action suit against your insurer, and find a clever way to make mention of it in your appeal. And be sure to "cc" the lead lawyer on that lawsuit ... this is a name that they will recognize.

Once you have written a bullet-proof appeal, and gotten it into the hands of the right decision-makers, you will not have to subject yourself to the nail-biting roller coaster of the "independent review."

Next time, we will talk about the so-called “peer review.” Are they really peers, whose side are they on, and how can you use them as “gold nuggets” in your appeal?

************************************************** *
I was at a party a few weeks ago, talking to an old friend. He said, “I keep trying to think of someone who might need your book, but I just don’t know anyone in that situation.”

“What?, “ I asked, “You don’t know anyone who has health insurance?”

THIS IS NOT JUST ABOUT RARE CANCERS.
THIS IS NOT JUST ABOUT CANCER.
THIS IS ABOUT ANY TREATMENT OR MEDICATION WHICH IS EXPENSIVE.

Hello. If you live long enough, you will eventually need something expensive from your health insurer.

Buy the book for all of your insured friends at my website: www.theinsurancewarrior.com (http://www.theinsurancewarrior.com)

Harrison

11-15-2007, 02:38 PM

Here's another update from our friend Laurie. Patients and doctors in Arizona may want to check out this event!
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Insurance Warrior Offers RX to make Insurers Pay

Cancer survivor Laurie Todd fought her health insurer’s denial of care and won; she now offers a battle-tested 10-step plan to help others fight back when insurance won’t pay.

The U.S. healthcare system is focused on controlling costs by denying care. This industry-wide posture causes everything from financial ruin to death. And yet the medical care that cost $1 million in 1970 would cost at least $16 million today.

Recent cancer survivor Laurie Todd has come to the rescue of patients nationwide. With her new book Fight Your Health Insurer and Win: Secrets of the Insurance Warrior, Todd shows ordinary people how to get insurers to pay their fair share.

Diagnosed in 2005 with appendix cancer, Todd was told by her doctors that post-operative treatment wasn’t necessary, and that her condition was manageable. Todd’s research suggested otherwise. The 57-year-old Washington native discovered a proven but expensive combination of surgery and chemotherapy, but was told by her oncologist, “There is no treatment for your disease. And, even if there were, they wouldn’t pay for it.

Ms. Todd worked tirelessly to appeal her insurer’s decision. First, she consulted with the world’s expert on appendix cancer. She then spent two months building her case—studying insurance law, gathering proof, and analyzing lawsuits against health insurers. Todd succeeded in getting her insurer to fully cover her lifesaving treatment, which totalled $345,000. Her share? Nine dollars.

Throughout 2006 Todd helped dozens of people, pro bono, to overturn denials of care—never losing a case. Many insurers, many conditions, all over the country. Seeking to spread the gospel further, Todd secured the backing of a major cancer research foundation to publish Fight Your Health Insurer and Win.

HEAR THE INSURANCE WARRIOR’S POWERFUL MESSAGE IN PERSON

Saturday, November 24 ● 10:00 a.m.

The Eccentric Gourmet
3434 W. Anthem Way #160
Anthem, AZ
ph. 623 551-4445

AZFamilyGuy

11-26-2007, 07:53 AM

Hi all,

1st time poster here, but I've poured over this board for hours upon hours and without even having spoken to any of you or replied in any of your threads, I feel like I know a lot of you. http://adrsupport.org/groupee_common/emoticons/icon_smile.gif

I'm posting in this thread to let you all know that I spoke with Laurie Todd yesterday - she was in AZ and setup an impromptu talk at a wine bar here in AZ. I was one of two people that showed up so I got a LOT of face time with her - it was awesome! I bought a copy of her book (haven't had time to read through all of it yet) and I'm assuming most of what she told me is in there already, but here are a few of the notes on writing insurance appeals that I took while talking to her (she told me to feel free to share it in my own words with everybody on the msg board):

- Make your appeal look like a professional report (i.e. title page, TOC, cover, etc.). Laurie mentioned that every appeal that she's heard of that was more of an appeal letter than a report has failed.
- Get precedent cases (people that have had their insurance pay in the past for your same operation)
* Get as much info as they'll willingly share with you (name, date(s) of surgery, costs (broken down into hospital, drugs, repeat surgeries, etc.) if possible)
* See this thread for a list of available precedent info: Precedents (http://adrsupport.org/eve/forums/a/tpc/f/3311036081/m/1031069192)

- Cite any bad advice you have been given
- Cite peer-reviewed articles concerning the procedure
- Never talk about any of your pain or anguish and never get emotional
* Here, too, Laurie mentioned that anybody she's heard of that ever included this in their appeal was denied - the insurance companies don't care about you or your life, it's all about money
- Send to the right people
* Find the medical director's name, address (sometimes googling or checking your insurer's website works)
* CC attorneys that have won cases against your insurer
- Include cost comparisons showing how paying for your procedure now will save them money in the longrun

Laurie also mentioned that she'd like to see someone on this site be the "keeper of the precedents". While I do plan on starting a thread requesting them, I won't label myself or perform the functions of the "keeper". I suppose this board, in a way (via attachments), could be construed as the "keeper" until someone steps into the role formally. I will also (assuming I write a successful appeal - which Laurie has high confidence in - she's already helped one person get ADR paid for) share my appeal with the community in return for any assistance I get from everybody. Laurie has also promised to send me a version of an appeal that was already written for ADR - with her blessing, I'll post that as well.

I have to say that it was very inspiring to talk to her and I would recommend everyone that has the opportunity to talk to her in person take advantage of it! I had to drive an hour both ways to talk to her, but it would have easily been worth much more of my time than it took. At the risk of sounding like a marketing/PR guy, I'd definitely recommend the book - $15 is pennies compared to what you could save with a winning insurance appeal. If nothing else, buy it to support her in her fight to spread her word so that someday this thread and all the other insurance related threads on this site won't need to exist anymore!

-Anthony

Harrison

12-02-2007, 08:53 AM

Reposted for MGS32, two different posts (now deleted) that refer to “The Insurance Warrior.”
________________________________________________

Hi All,

I recently exchanged a few emails with the "Insurance Warrior" (Laurie Todd) and I wanted to post her responses, in case the answers can help anyone else. I'll post both my question and her response below:

My Question -- I work for a private company, which I've been told is self insured and has more of a health insurance "administrator". (I'm not sure of this, but it's something I need to find out). If this is the case, do you know if this will drastically change the plan of attack I take in making my appeal?

"Insurance Warrior's" Response -- Yes, the fact that the company is self-funded makes ALL the difference in how you approach your appeal.

I've done a few self-funded ones, and I have written an article about them. I will also send this to you when I get home.

With a regular insurance plan, the insurance company gets to decide if you get your treatment. When they deny your treatment, you intimidate the insurance company until they pay. The insurance company is subject to state insurance law, and the Insurance Commissioner can be of help, or take your complaint.

In a "self-funded" plan, your employer gets to decide whether you get your treatment/surgery. The money to pay for your surgery comes directly out of the employer's checking account, so they get to decide. In this arrangement, there is no insurance company. All of a sudden, the insurer (Blue Cross, Regence ... no matter who they are) magically turns from an insurance company to a "third party administrator." Your employer is not considered by law to be an insurer, and your insurer is not an insurer.

So ... in the self-funded plan, the insurer and employer are not subject to insurance law, and the Insurance Comissioner cannot help you.

If your appeal gets denied enough times (depends on the plan, usually three or four), the only entity that you can appeal to is the FEDERAL GOVERNMENT (Dept. of Labor). Good luck with THAT! The appeal time with the D.O.L. is six months. Forget it ... you must write an appeal strong enough to nail both the insurer and the employer before you get to that point.

One of the gnarly things with self-funded plans is that the "insurer (third party administrator)" and the employer may hide behind each other. If you talk to the insurer, they say, "We don't have any power to approve this." If you talk to the employer, they say, "We just go by what the Medical Director of the insurance company decides."

Some of the smaller companies who use this set-up totally don't play by any kind of rules, because there is absolutely no regulation of their "insurance" activities. I remember one ADR case where the employer said, "Your husband is a high-level manager here. He already has more benefits than most other employees. If we GIVE you this surgery (as though it were a gift of some sort), other employees will be jealous."

OUTRAGEOUS. If there is any law against it, it is probably a labor law, or some kind of federal statute. If that were me, I would have dug until I found it ... and totally rubbed their noses in it. This person gave up at that point, because she was afraid of further antagonizing the employer.

I fought one of these in person with a local couple. The employer was Boeing, and the "third party" was Regence ... it doesn't get any bigger than that. I had to aim directly at the head of the Medical Director of Regence, and directly at Boeing. It was an in-person hearing. Six Boeing vice presidents, two Medical Directors of Regence, and one corporate attorney. I wrote a speech for the patient's wife, and a speech for me. It was extraordinarily tricky, extrarodinarily difficult, scary as anything. We wiped the floor with them, and they decided to pay within twenty-four hours.

It was after that case that I decided not to get that involved with future appeals.

You need to request your surgery, get denied, and find out where the resistance is coming from. Then, you need to ditch all fear of insurance companies, and all fear of employers. You must intimidate both parties sufficiently to get the job done (make them pay). You must be so intimidating, and so excruciatingly polite, that they don't even THINK about retaliating.

These self-funded plans are horrible news for employees who get sick or need expensive healthcare. Not only do you lose protection of insurance law and the insurance commissioner, but you often have to fight your employer when your are really sick, and most afraid of losing your job. Worst aspect of self-funded plans? The company sets aside x-number of dollars each year to pay for medical treatments. If you come down with cancer towards the end of the year (or fiscal year), they will be just plain out of money, and you just plain won't get any treatment.

Why do companies go for the self-funded plans? They didn't work back in the 1970's, and they don't work now. Companies go for them because they are advertised as "money savers" by the insurance companies. The company gets to save money because the premiums are less than for traditional insurance, and the company gets to control the purse-strings. Further, the insurance companies aggressively push these plans, because a self-funded plan instantly frees them from all regulation.

Find out how the two sides work together at your company. Who is calling the shots, who is standing in your way? Then, put on your velvet gloves, and wield your mighty sledgehammer of facts with the precision of a scalpel.

Feel free to share this verbiage on the ADR website ... I like to help the greatest number of people. Just tell 'em where it came from.

Laurie Todd
The Insurance Warrior

Hi All,

One more email exchange I had with the Insurance Warrior that I wanted to share...

My Question: My question is whether I should hold off on having my doctor's secretary send in a pre-determination letter for my insurance until the ProDisc-C has been FDA approved. A little background: My neurosurgeon told me last week that he had received word that, as of the 1st of the year, he would be able to use the ProDisc-C at two levels off trial. On October 25th, Synthes received the Approvable letter from the FDA for the ProDisc-C, but they have not yet received FDA approval. I spoke to the director of reimbursement at Synthes today, who told me they expect to get FDA approval very soon, but he could not give me an exact date. I assume that my doctor must have been at some conference where this announcement was made that Synthes expects approval by the 1st of the year. So, the director of reimbursement told me I was crazy to submit for insurance approval before FDA approval was announced. Of course, I am anxious to get this process started so that I can hopefully get surgery soon and start feeling better. But, I don't want to hurt my chances by applying prematurely. Any advice/suggestions you have would be great!

"Insurance Warrior's" Response - These "Directors of Reimbursement" ... what do they do? They pay them good money, I presume.

The first of the year is not that far away. However ...

You've read the book by now, yes? What does "experimental" mean? THERE IS NO DEFINITION OF IT. IT MEANS THAT THEY DON'T WANT TO PAY.

They (employer/insurer) don't care if the treatment is good for you or not, is proven or not, is FDA-approved or not. Why doesn't this "Director of Reimbursement" know this?

Insurance companies deny treatments that are FDA-approved every day of the week. They call treatments "experimental" that they have paid for hundreds of times, that they just paid for last week.

Furthermore, when they receive our blockbuster appeals, they paid for treatments that are NOT FDA-approved, that are only offered in other countries, that they have NEVER paid for before. Why? BECAUSE WE INTIMIDATE THEM INTO IT.

By all means wait a month for FDA approval if you want to. However, waiting for such a thing demonstrates that you haven't totally wrapped your mind around this denial of care thing and how it really works.

Just know that an insurance company has NO CRITERIA WHATSOEVER for deeming treatments "experimental" or "not medically necessary." They don't know, they don't care. That's why all of these appeals that detail your terrible quality of life, explain why the treatment will help you, etc. will fail. BECAUSE THEY DON'T CARE ABOUT ANY OF THAT.

It is simply their job not to pay, and your job to make them pay.

You make them pay by preparing a twenty-plus page appeal document. Don't give your whole medical history ... they already know that. Only tell the things that the in-network doctors did wrong. List a dozen different cases (name names, give dates and surgeons) where they paid before. Prove that the treatment is tried-and-true, with excellent results. Attach peer-reviewed articles to meet all objections. Omit all feeling words, sound like the most polished attorney. Make certain that your appeal document gets to the right decision-makers, with copies to important people who will check up on your addressee.

This is all in the book, I've restated it in the Ten Steps. Do exactly what I say, and they will pay.

Share this with your friends on the ADR site, and please remember that -- for both you and the insurer -- this is all one high stakes chess game, one big bluff.

Thank you for letting me rant a bit. They should be paying me instead of all these Reimbursement Specialists. I have won twenty-eight of these, and lost zero. They, from what I have been told, get about a 50% approval rate. I seem to be the only one who understands that this whole denial of care thing is all smoke and mirrors. The insurer is not waiting to be convinced. They are waiting to see if you are clever enough to call their bluff.

Laurie
___________________________________________

Harrison

12-04-2007, 06:38 PM

The Insurance Intelligencer
12/2/07

The Peer Review

What is the “peer review,” and how can we turn it to our advantage?

Let me take this opportunity to explain—one more time—that the health insurer’s assertions and objections are all smoke and mirrors. Following is a quick refresher course, just to get you in the correct analytical state of mind:

1. What does “experimental” mean?

Nothing. Whatever your health insurer says it means. There is no agreed-upon definition for “experimental.” No matter how I explain this, folks still try to make sense out of these pronouncements by the insurance company. They say, “It must mean ‘not FDA-approved,' right?” Wrong. Health insurers deny FDA-approved treatments every day of the week, and they approve treatments that are not FDA-approved every day of the week. But only if we submit a powerful written appeal to the right decision-makers.

2. If my out-of-network benefit is 80%, I have to pay the other 20%, right?

Wrong. If you write a strong enough appeal, tell all of the things they did wrong in your treatment, quote all the incorrect and embarrassingly untrue things the in-network doctors said, and list two dozen times they have paid for this before, they will be eager to pay the in-network rate, with no patient responsibility. Every item in your benefits booklet is negotiable, except the lifetime maximum.

Onward to the peer review ...

Let’s say that you request a treatment/surgery/medication, and your insurer denies the treatment, stating that it is “experimental, out-of-network, not medically necessary.” At some point in the entire appeals process – could be after the first appeal, could be later – your case may be sent for a “peer review.”

I’ve put you in the appropriately suspicious state of mind, yes? What exactly is this peer review? Many never ask this question. The insurer comes back to them, saying, “The peer reviewer has denied the treatment.” Cast in stone, right? A doctor who is expert and informed about this treatment has said “no,” right?

NOT NECESSARILY. Just start digging, and you may be able to show, once more, that the Health Insurance Emperor Has No Clothes.

One of my brilliant helpees was involved in requesting a very cutting-edge, state of the art radiological treatment for liver metastases. The radiation oncologist who administers this treatment has a twenty-page resume, and a list of published papers as long as your arm.

The case manager says, “The case is going to the peer-to-peer review.”

My helpee managed to weasel the name of the reviewer out of his case manager. Guess who this “peer” was ... a family practice doctor with no special training in oncology, radiology or liver tumors who works for the insurance company. He denied the treatment within one day ... do you think that was long enough for him to study up on the latest treatments for liver metastases?

Dr. Hired Gun’s job is, I suspect, similar to the job of the doctor who is employed by the auto insurer. You know, the one who finds all the ways in which you are not injured.

Once we figure this out, how do we turn it to our advantage?

Simple. Make it a point in your written appeal. Find out who the “peer” is. Make a few statements about the qualifications of your expert-of-choice, and a few more statements about the complexity of the treatment. Mention the three hundred peer-reviewed studies by your doctor-of-choice. Then say, as naively as possible, “Dr. Expert is a surgical oncologist with thirty years experience doing this incredibly complex procedure. I was surprised to learn that Dr. Hired Gun is an OB/GYN, two years out of medical school, who is employed by Acme Insurance.” The assumption being ... your peer was not a peer, and his review holds no water.

Now THAT will be very embarrassing to Acme Insurance, when they see it in print.

**************************************************

Philosophy Corner

This is my last newsletter of the year; it is time to wax philosophical.

In December 2005, I was sitting around listlessly in my Pillsbury Doughboy pajamas at my friends’ home in Washington, D.C., watching HD TV all day. I had just been sprung out of the hospital after undergoing the Mother of All Surgeries and spending forty days of suffering in the hospital – relieved only by several near-death experiences. I did not know if I would ever have the strength to pour my own glass of juice, and I didn’t have the strength to care.

December 2006. I had by now won two dozen appeals for others, written a book, found a cancer foundation to fund the project.

December 2007. This year, I published the book myself, sold two thousand of them, helped win another dozen appeals, and started the speaking career.

December 2008? I would like to speak at many conferences, sell many boxes of books, and affect how health insurers decide about care. Publish a second book – how about a do-it-yourself appeal workbook, with jaw-dropping helpee success stories woven in? I think big ... who would have predicted what I have done since I was told in March 2005 that I had months to live, and that there was no treatment for my disease.

Perhaps the most important work that I have done during the last three years is to grow in compassion. Sometimes painfully, but always to the good. And to use the words “good” and “bad” much less, choosing instead “desirable” or “undesirable.” Cancer? Undesirable. Becoming a published author? Desirable. Both part and parcel of the ten thousand joys and sorrows that comprise a full life.

Thank you to my readers, friends, and helpees for being brilliant and compassionate participants these past three years ... and for many years to come.

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Need an inspiring gift? One size fits all? How about the book “Fight Your Health Insurer and Win”? Let’s hire me to speak at conferences,get these books to those who need them, and make room in my storage unit for Book Number Two!

Harrison

04-15-2008, 06:20 PM

The Insurance Intelligencer
4/15/08

“The Doctor Wrote my Appeal”

When I first heard this, I was baffled. I wondered ...

1. Whose doctor would write an appeal?
2. What kind of an appeal would a doctor write?
3. Why would a patient trust anybody but themselves to write an appeal?

If you had asked me three years ago, “Why don’t you have your doctor write an appeal?” ... I would have laughed till I cried. Not only weren’t my local doctors interested in writing an appeal, but they were dead set against me getting any treatment at all, saying ...

1. “You don’t need any further treatment.”
2. “There is this Dr. Sugarbaker. However, if you went to him, you would be disabled.”
3. “There is no treatment for your disease. And, even if there were, they wouldn’t pay for it.”

Like I would trust any of these individuals to write an appeal for me?

I have learned much in the last three years. When people find themselves in Big Medical Trouble, their first reaction is to call the insurance company. Once they figure out that they aren’t getting anywhere with their insurance company by phone ... they call their doctor.

Once upon a time – before the coming of Managed Care in the 1970’s – your doctor would have been the one to call when the insurer said “no.” Back then, your doctor’s practice was an independent entity. It was his job to find the best treatment for you, to request it of the insurance company, and to persuade them to pay for it.

Back in 1970, in their quest to control skyrocketing medical costs (How well has that worked?) the insurers came up with a brilliant concept. Let’s build a building, put all the doctors in it, pay them a salary, and put a contract in place that says that the INSURER gets to decide what treatments get paid for.

Voila, the HMO is born. PPO, POS – whatever type of insurance you have, your doctor is contracted with the insurance company, and you live according to the principles of managed care.

There are two types of doctors that you will encounter: Doctors who are contracted with your insurance company (in-network), and doctors who are not contracted with your insurance company (out-of-network). Let’s see what happens when each type of doctor writes your appeal.

In-network doctor writes appeal

He is contracted with the insurance company. Therefore, it follows that he is not in the best position to mount a powerful appeal to make the insurer pay for something they don’t want to pay for.

Sort of like a quarterback going for a touchdown for the opposing team.

Out-of network doctor writes appeal

The doctor who is not contracted with your insurance company (often your expert of choice) has no influence with the insurer whatsoever.

What repercussions are there if an out-of-network doctor asks for a treatment for you, and the insurer still says no? None.

See where I am going with this?
The only person who has any traction with your insurance company is YOU.

What kind of appeals are doctors writing?

In 99.9% of cases, they are not writing appeals at all. Best case scenario, they write a one-page letter saying, “The patient really needs this treatment.” More likely, they have a form letter in their files that says, “The patient really needs this treatment.”

There is an exception to every rule, of course. I have met one doctor who personally engages in appealing insurance companies. It is very frustrating for him, and it takes away from the highest and best use of his time, which is performing lifesaving procedures.

I have advised him more than once to buy a supply of my books, issue one to each new patient, and get the patients on board to write their own appeals.

When your life is on the line, is a one-page form letter good enough for you?

Laurie the I.W. speaks to an Appeals Coordinator

A prospective cyberknife patient contacted me ... her first two appeals had failed. I asked, “What did you put in the first two appeals?” “My doctor did the appeals,” she answered.

She then suggested that I speak to the Appeals Coordinator. I eagerly anticipated speaking to someone who actually gets paid for what I do.
I asked the paid appeals expert, “What did you put in the first two appeals?”

“Well, it was a letter,” she replied.
“How long of a letter?” (Laurie)
“One page and some articles.” (Appeals Coordinator)
“How many articles?” (Laurie)
“Two.” (Appeals Coordinator)

Two. I almost fell off my chair. Since I have no censor anymore, I said, “When I write the third appeal, the letter will be twenty pages long. I will attach at least twenty-five peer-reviewed studies and articles (specifically about cyberknife and liver tumors). I will go to the FDA website, and find written proof that the cyberknife equipment is FDA-approved, and exactly what kind of FDA approval it has. Then, I will go to the CMMS (Center for Medicare and Medicaid Services) website, and find the written evidence that Medicare is reimbursing for cyberknife for liver lesions.

Then, I will go out into the online support groups, and find thirty-plus cases where major insurance companies have paid for this before (precedent).

Bottom line? Do not leave it to your doctor to write your appeal.

***************************************

Would you like Laurie the I.W. to speak to your group?
Just ask, and I will send you my Speaker Info Package.

Isn’t it time that your medical provider issued a copy of my book to every new patient? I will be happy to send him or her my Provider Package.

Happy and peaceful Insurance Warrior-ing,

Laurie Todd
laurie (at) theinsurancewarrior.com

Harrison

05-28-2008, 08:49 AM

Just an update from our friend Laurie Todd...

Dear friends, readers and helpees --

The Insurance Warrior was featured on the Seattle news yesterday.

If you want to see me in person -- making a spectacle of myself in front of thousands -- here is the link (copy and paste):

http://www.king5.com/health/stories/NW_052708HEB_insura...ior_KS.35ff2d7d.html (http://www.king5.com/health/stories/NW_052708HEB_insurance_warrior_KS.35ff2d7d.html)

Please share with everyone who has health insurance, anyone who needs a keynote speaker, and all who need to hear this message.

Peaceful Warrior-ing to all,

Laurie Todd

ans

05-30-2008, 01:25 PM

This is probably incidental but I've written to Laurie and she seems like a very nice person.

Harrison

06-18-2008, 04:49 PM

The Insurance Intelligencer 6/15/08
It's YOUR Appeal

Last week I received an email from Jean. She had read my book, and she had a question:
"My husband needs Erbitux. The appeal has been denied. Our next recourse is the Department of Managed Care. Any tips for us?"

I already knew from this message that Jean didn't get it. However, I asked a few questions in order to get Jean to realize that she hadn't gotten it.

1. Why is it that most insurers do not want to pay for Erbitux?

Jean's answer: The money?

Jean hasn't done her research. She doesn't grasp yet that, if appeals are all about money, then we have to know exactly how much everything costs. How much does our requested treatment cost? What treatment would Acme Insurance rather offer you, and how much would THAT cost?

Erbitux (Cetuximab) is the most expensive prescription drug on the planet. A monthly dose costs at least $16,000. Erbitux is a perfect example of an exciting new cancer treatment. The only thing not so exciting is that all of these new cancer treatments will be scary-expensive, and your insurer will not want to pay for them.

You need to know what you are asking from your insurer, money-wise, before you even consider writing an appeal.

2. Who wrote the appeal that failed? What was in it?

Jean's answer: My doctor wrote the appeal.

As my loyal fans and readers know ... "My doctor wrote the appeal" is not an answer. If your doctor is contracted with the insurance company, he is not ideally positioned to mount a powerful appeal for you. If your doctor is not contracted with the insurance company, he has no say with them whatsoever.

Most doctor-written appeals are one- or two-page form letters, which say, "The patient really needs this treatment."

Is that good enough for you?

If you didn't know better at the time, and the doctor did write your losing appeal ... GET A COPY OF IT. Before you can write your own winning appeal, you need to know what didn't work.

3. How do you know that your only recourse is the Department of Managed Health Care?

Jean's answer: We were told ...

"We were told" is not an answer, unless it is immediately followed by " ... and then I looked it up myself."

People, please. When a treatment is denied, the first thing to do is go to your benefits booklet (or the insurer's website), and study their appeals procedure. This is your roadmap, your pathway to approval, your freeway to success.

It is incomprehensible to me that someone could already have one denial, not have any idea what was in the failed appeal, and not know for themselves what levels of appeal were available to them.

Don't ask ME what appeals are available to you ... that is up to your insurance company. By law, this appeal information must be provided to you. It is part of your job as an Insurance Warrior to know the appeals procedures, and follow them to the letter.

By the way, if you call six people at Acme Insurance about appeals, you will get six different answers. "We were told" is a very dangerous -- often fatal -- condition in which to remain.

My questions to Jean regarding where she stands in the appeals process:Who told you? Do they know what they are talking about? What does it say in your benefits booklet? Usually appeals don't go straight from one denial to a government agency.

Since you are under the impression that you must now rely on the Department of Managed Health Care (a California government agency) ... have you studied all about them, and researched THEIR appeals procedures?
I pointed out to Jean that we do not expect government agencies to win our appeals. We do not expect doctors to win our appeals, we do not expect lawyers to win our appeals. We do not expect insurance brokers to win our appeals, we do not expect politicians to win our appeals. And we certainly do not expect Insurance Commissioners to help with our appeals, much less win them.

Whatever you do, I told Jean, write your own appeal. If you must submit some type of form to the Department of Managed Health Care, make your twenty-page appeal an answer to one of the questions, attach it ... and be sure to copy the right decision-makers. Who should you copy?

- The Medical Director of the insurance company
- Two suitable Vice Presidents of the insurance company
- The Executive Director of the Medical Society of your state

No government agency is ever going to move fast enough to save your life. If you have to funnel your appeal through a government agency, you need to get it back through the doors of the insurance company, through your "carbon copies." If you have written a powerful-enough appeal document, the insurer will approve it before the Department of Managed Health Care ever gets around to looking at it.

Thankfully, we are on our own when it comes to writing and winning our appeals, because nobody will ever do a better job than we will.

Of course, it will be much easier for you than it was for me, because my book explains exactly how it's done:

Fight Your Health Insurer and Win: Secrets of the Insurance Warrior Available exclusively at my website: www.theinsurancewarrior.com (http://www.theinsurancewarrior.com)

*********************
Or invite the Insurance Warrior to present a seminar or talk to your group.
Contact: laurie@theinsurancewarrior.com for the media package.

Happy and peaceful Insurance Warrior-ing!

Laurie Todd

If you haven't watched the YouTube video yet, take a look, and leave a comment!
http://www.youtube.com/watch?v=HE_TuDQIwpw

Terry

06-18-2008, 07:52 PM

Nice Post. It basically tells us that our destiny is in our own hands, where it should be.

To thine own self be true.

She has excellent advice and a road map to follow.

Thanks for posting this Richard and I hope it helps a great many people.

Terry Newton

Harrison

10-12-2008, 11:38 AM

The Insurance Intelligencer : 10/10/08

*****************************

Insurance Company Words

Treatments are denied with words, and treatments are approved with words. I win all of these appeals because I understand insurance company words.

I have an M.A. in French Literature. This unlikely credential means that I am trained as a literary critic. To me, all words are propaganda. And it is my job to figure what they are trying to brainwash me to do.

Insurance words have two goals:

1. Make you feel very, very safe and cared for.
2. Keep the power in their hands.

Once we understand how insurance propaganda is deployed, we will not be stopped by it. As a matter of fact, we can use it to our advantage.

Names of insurance companies

Let's begin at the beginning. The name of the insurance company is designed to make you feel that they are on your side, and that they will keep you safe. What is the name of your insurance company?

Blue Cross/Blue Shield ... The insurer is my cross and my shield.
United Healthcare ... We are united. We have health. We CARE.
Neighborhood Health ... We are your friendly neighbor.

My favorite insurance name of all time? A man from Illinois called me. He had had brain surgery, and the insurer didn't want to pay for it. I asked, "What is the name of your insurance company?" He said -- I kid you not -- "Golden Rule Insurance."

Do unto others as you would have them do unto you. For crying out loud ... how would the Medical Director of your Golden Rule Insurance like it if they wouldn't pay for HIS brain surgery?

Don't be lulled into complacency by the name of your insurance company.

Names of departments at insurance companies

It used to be called "customer service." We are eager to serve you. But customer service has been amped up to "Customer Care." We CARE, we really do.

United Healthcare gets the Laurie Todd Hooplehead Award for the most devious department name of all time. A nice gentleman from Wisconsin called me one day. He had a rare form of testicular cancer, and UHC suddenly stopped paying for the only treatment that was keeping him going. He send me a heartrending account of the hundreds of fruitless phone calls that he had made to UHC, the call-back promises that were never kept, etc. Guess what department he was dealing with?

The Rapid Response Resolution Team

The job of the Rapid Response Resolution Team is to never, ever, under any circumstances call you back.

Names of people at insurance companies

Peope at insurance companies keep the power by not telling you their names. They will give you their first name, and a phone extension. Ever try to call that extension? They never work. Joke's on you.

What message does withholding of names send?

o I am not accountable.
o You will have to tell the whole story all over again next time.
o Any promises that I make are empty.
o I am really not here to help you, and I don't care.

My favorite name incident of all time? One of my helpees called the insurer, and asked for the name of the Medical Director. The "customer care" person answered, "Oh, we are not allowed to speak his name."

Is this like the thousand names of God? We dare not speak his name? I know that Medical Directors have divine rights over our life and death, but this is ridiculous!

Denial of care words

Now we understand that words are meant to persuade. We will not take them at face value. Insurance companies always use the same three phrases to deny care. What are they, and what do they make us feel?

Experimental/investigational

When I ask people what experimental means, they say, "not proven," "no randomized trials," "not FDA-approved." I have news for you. Insurance companies have paid for treatments that weren't FDA-approved, and they have denied treatments that are FDA-approved. Denial or approval is totally capricious.

There is no "experimental" list. Insurers have denied treatments as experimental, when they just paid for them last week. They have denied treatments as experimental, when they have paid for them hundreds of times. There is no substance, rationale, or logic behind these denials.

If your treatment is denied as experimental, just look up your insurer's definition of experimental, and disprove it in your appeal.

Not medically necessary

Does this mean "not needed for my health"? "Not needed for me to survive"? Has my insurance company done a lot of research to determine whether I need this treatment or not?

People, please. "Not medically necessary" is not a medical term. It is a legal term. This phrase was invented along with managed care back in the 1970s. It removes decision-making power from your doctor, and grants it to the insurer.

Go to your benefits booklet, and read their definition of medical necessity. Somewhere in the bewildering paragraphs of legalese, it will say: "Medically necessary as determined by the Medical Director of Acme Insurance Company." Because we said so.

Leap over this objection, there is no substance to it.

Out of network

The lifesaving treatment that I need is out of the network. I have no out-of-network benefit. That means that I have to sell my house to pay for it, right?

Wrong. If your health will suffer without this treatment, they can be persuaded to pay for it. Simply go to my new improved website, and use the appeal template from my "Winning Appeal Workshop," (www.theinsurancewarrior.com (http://www.theinsurancewarrior.com/)) and plagiarize to your heart's content.

The emperor has no clothes. Denials are bluffs. Just make your bluff better than their bluff, and you win.

**********************

Catch my WEBINAR on Tuesday, October 14 -- 3:00 p.m.
You need to register, and it is FREE
Tuesday, Oct. 14 -- 3:00 p.m. EST
https://cc.readytalk.com/registration/1es5043e6p7fd/14pnn9knkmg3c (https://cc.readytalk.com/registration/1es5043e6p7fd/14pnn9knkmg3c)

Harrison

11-05-2008, 07:30 PM

The Insurance Intelligencer
11/5/08

Lifetime Maximum

People often ask me, "What is the most pressing issue about health insurance?"

Snarky answer? All of them.
Two-word answer? Cost shifting.

In case you haven't noticed, your health insurer is constantly finding new ways to shift healthcare costs to you:

Higher deductibles
Multiple deductibles (office visits, drugs, out-of-netword, hospitalization)
Higher co-pays
Higher out-of-pocket limits
Higher costs for going out-of-network
Out-of-network maximums
Shorter list of covered prescription drugs
Yearly maximums for prescriptions
Varying percentages paid for different lists of drugs
Once these cost-shifters are in place, you will be surprised how fast the expenses add up. You have "good insurance." You are diagnosed with breast cancer, or colon cancer. Within a year, you could easily rack up $50,000 in medical expenses that are not covered. Happens every day.

So ... you mortgage the farm, sell the horse, and get through your first year of cancer survival. At least you still HAVE insurance. Or do you?

Insurers have two ways of cutting you loose, when you become too expensive (i.e., sick): Recission, and the lifetime maximum.

Recission

Recission is the lesser problem. However, it does happen, and you need to be aware of it.

The word "recission" means "the cancellation of a contract." This is how it works. You are diagnosed with cancer. You ring up many dollars in medical expenses. When you reach a certain dollar amount, bells and whistles go off over at Acme Insurance. "Beeep! This member is getting too expensive!"

The bean-counters at Acme then pull up your original application, and pore over it to see if there are any irregularities that they can seize upon, in order to cancel your policy entirely. These "irregularities" are often made to fit into the category of "pre-existing conditions." Insurers have gone so far as to assert that you had an ache or pain ten years ago, you should have known that you were going to get cancer, we're cancelling your policy.

Recission is not practiced by all insurers, because it borders on the illegal. Anthem Blue Cross recently settled a lawsuit for $11.8 million dollars ... for "unlawful and deceptive business practices" -- claim denials and unjustified recissions.

Recission is easily overturned with a powerful appeal, so I am not overly alarmed about it. There is, however, a looming danger to all insured people. They can get rid of you, and there is nothing that you or the Insurance Warrior can do about it.

The Lifetime Maximum

The majority of us have a lifetime maximum. The most common figure is $2 million. Sound like a lot of money? I have seen people with cancer run through $2 million in eight months. Eight months is not a lifetime.

When you have maxed out your health insurance, you are done. Cut off. It's cash out of pocket from that point on.

The current lifetime maximums were set back in the early 1970s -- by insurance companies. They have not been raised since. I do believe that, in 1970, the insurers made a good faith effort to figure out how much it would take to cover the average person for a lifetime.

In 1970, my grocery budget was $15 a week. The medical care that cost $2 million in 1970 would cost approximately $36 million today.

Why have these lifetime maximums never been raised? Because it is not to the economic benefit of insurance companies to do so, and there is no law requiring them to do so.

More people are maxing out their insurance every day.

What to do when you max out your insurance? Some states have a risk pool of "uninsurables," which is what you now are. Sounds a little bit like "undesirables," doesn't it? The coverage is expensive, and limited to the basics. You get to be on their waiting list after you run out your insurance, then get turned down by two insurance companies.

http://www.healthinsurance.org/riskpoolinfo.lasso (http://www.healthinsurance.org/riskpoolinfo.lasso)

Keep an eye on your lifetime max. This is the fixed amount that your insurer will ever spend on you. It is your "medical checking account," and it dwindles with every treatment you receive. Use it wisely.

Plus -- when we have new elected officials -- implore them to reign in the wild horses of health insurance, and make them raise these lifetime maximums that are forty years out of date.

Check out my free Winning Appeal Workshop

Ask a question! Leave a comment!

http://blog.theinsurancewarrior.com/blog1/ (http://blog.theinsurancewarrior.com/blog1/)

Happy and peaceful Insurance Warrior-ing,

Laurie Todd
www.theinsurancewarrior.com (http://www.theinsurancewarrior.com/)

Terry

11-05-2008, 10:53 PM

KBear

11-06-2008, 01:16 AM

I am definitely not for universal health care either; but something has got to give. My family spends $1,200 a month on co-pays, prescriptions, out of pocket, deductibles, and premiums (and no one has had any major surgery). This is $14,400 a year, some people don't even make that in a year. Others make double, maybe triple that. Even at an income of 3x that, $43,200 a year, that would make your medical spending 33% of your income. How in the world does one support a family and pay that kind of money? I am very fortunate that we are able to afford that and still live comfortably, but so many can not.

For instance, my brother got married 2 years ago, at age 28. He and his wife, 26 years old, bought a home (the American dream), and started building their life together. Like so many of us (myself included), as a young married, health insurance was the furthest thing from my mind. We were young and healthy and had 'better' ways to spend that premium, thus making the choice to forgo insurance. They checked into insurance and decided it wasn't in the budget; but were planning on getting it in a year and planning to start a family. One year and two months after the wedding, my brother was shocked to find a lump in his testicle. He went to the doctor, thinking that it was nothing; but got it checked due to his wife's insisting (her mom was battling breast cancer and she was in high alert mode). The doctor decided he wanted to have it surgically removed and do further testing.... A month before my brother turned 30, he was diagnosed with testicular cancer that had already spread to his stomach and lungs. He then began cancer treatment, with no insurance. He did have a small 'nest egg' set aside, which didn't last long. He paid 10K to have a central line implanted.

Another 12k for testicle removal, numerous testing, etc. It was not long before the 30k 'nest egg' was gone. He then had his first chemo, in the hospital, since it was so strong that he was high risk for having his body shut down and needing to be brought back. They put money down and made a payment plan upon admission. The plan was for 5 days in, 8 hours a day of chemo, then 3 weeks 'off', with one outpatient treatment for 8 hours at the hospital each week, then 5 days 8 hours in hospital. He finished he first 5 days in the hospital and returned 4 days later for his outpatient day and was refused treatment. He was told that without paying the bill in full for the prior treatment he could not be treated, even though he had made a down payment and payment arrangements. He did not qualify for goverment assistance as his income was too high. He has been fortunate to have a dr who helped him get discounted chemo in the dr's office, as well as family and church family who have contributed financially to his care. This is all because he made a gamble on his health, by having no insurance and lost. One year later he is saving to have a 'mass' removed from his stomach, which may or may not be cancer.

Then, back to testing for cancer clearance. Also, he will NEVER be insurable, no one will take him with cancer in the history, no life insurance, nothing. All for one case of bad judgement in not having insurance. We, as Americans, can not allow our fellow Americans to die for bad judgement, lack of money, or unforseeable circumstances; something has got to change. Although, from what I have read and heard about Canada's health care system, that is not the answer.... months waiting for a dr visit, a diagnostic tool, a surgery, etc. that could be life or death for many. Stepping off my soapbox now....

Harrison

12-09-2008, 03:27 PM

The Cure for Cancer

We donate for the cure. We research for the cure. We climb, walk, race for the cure.

When the cure is found ... it will be very, very expensive.

What good will that cure be, if your insurance won't pay for it?

********

One day, you are sitting in your doctor's office, worried and waiting. He tells you that you have cancer. What treatments will be offered to you?

What treatments will your doctor offer?

The ones that he happens to know about. He is not all-knowing.

The ones that he approves of. His criteria may not be the same as yours.

Generally speaking, he will offer the treatments that are available within the insurance network.

Disclaimer: Many of your doctors are providers for the insurance company, and will fight the insurance company if necessary in order to get the best treatment for you. We cannot assume that all doctors are doing this, however.

The insurance company is a business, not a social service agency. When you meet with your doctor, your are sitting face-to-face with the representative of the insurance company. It is his job to reduce operating expenses, by controlling access to services.

I am not being cynical. That is his job. He is the gatekeeper.

Of course, it is also his job to treat whatever medical problem you came in with. Sound like a pretty serious conflict of interest? It is, for all concerned.

The simplest way for your doctor to treat you -- while still controlling costs -- is to offer you whatever treatment is available on his list, in the network, by providers whose fees are determined by the insurance company.

What if your child has a brain tumor, and the only surgeon with the skill and will to remove the tumor does not happen to be contracted with your insurance company? I have news ... many of the most talented and experienced surgeons are no longer contracted with most insurance companies. Don't count on your doctor knowing about this surgeon, or telling you about him.

How do new treatments become standard of care?

Short answer? They don't.

Do you really think that your insurance company is putting forth a big effort to figure out how to shell out more dollars for expensive new medical treatments?

There is no path whereby treatments become "standard of care" for insurance companies. I fight every day for treatments that have been ...

FDA-approved
Tried, tested, and proven for thirty years
Studied in randomized trials
Published in peer-reviewed medical journal articles
Paid for hundreds of times by the insurance company
Yes. A treatment that Acme Insurance paid for will be denied by Acme insurance three days later as "experimental." Not only is there no path by which new treatments are evaluated and accepted by insurance companies ... they continue to deny treatments that they routinely pay for.

I have fought Regence of Washington six times over the past eighteen months for the same cancer surgery. Each time that a new patient needs this surgery, they call it "experimental" all over again.

How long will it be before the Medical Director of Regence in Seattle tires of receiving my 86-page faxes in the middle of the night? They will fund your effective, proven out-of-network treatment. But only if you are ready to fight for it.

McDonald’s or gourmet?

Much of this research seems to be focused around finding the "magic pill" to cure cancer. Preferably a pill with no side effects, one that my insurance will pay for. However, the likelihood of such a cure seems rather remote to me.

Meanwhile, many patients are having very good outcomes, with very advanced and difficult cancers. The treatment that saves them is not easy, sexy, exciting or new ... it is good old-fashioned skilled surgery.
For many of us cancer patients, surgery is still the gold standard, and surgery is the only path to long years of health with no recurrence.
The surgeon with the best outcomes is not always a provider for your insurance company.

In one of my recent appeals, the insurer denied an out-of-network cancer surgery, stating that the surgery was not "evidence-based medicine." This insurer was currently funding systemic chemotherapy for this patient to the tune of $40,000 to $60,000 per month, with no scientific evidence that it would benefit him. This chemotherapy would continue until the patient died, or couldn't tolerate it anymore.

Since you are spending so much dough anyway, I suggested, why not spend the $40,000 for the definitive surgery that might actually fix the problem?

I believe that I have finally figured out why insurers are so eager to recommend systemic chemotherapy, even in cases where it has never been found to help, and even though it is so expensive.

Each insurer delivers medical care to thousands or millions of people. Sort of like McDonald's, which serves food to millions of customers.

Why is McDonald's offering hamburgers, instead of soufflés?

In order to serve a thousand hamburgers, all you have to do is buy a big vat of nasty factory-farm beef, and deliver it to McDonald's. There, a revolving cast of interchangeable employees are able to turn out identical meals.

Preparing a soufflé, however, requires more expertise, and is more labor intensive. It requires a skilled chef, ready in the kitchen to perform at the top of his game.

In order to treat a thousand cancer patients, all you have to do is buy a big vat of nasty toxic chemicals, and deliver it to the medical facility. There, a revolving cast of interchangeable medical personnel are able to deliver identical treatments.

A curative cancer surgery is more labor intensive. It requires a skilled surgeon, ready in the operating room to persevere until all of the cancer is removed. Surgeries are longer, patients are sicker, and better outcomes are achieved. Not in keeping with the "serve the lowest common denominator" school of insurance-driven care.

Systemic chemotherapy is the best and most appropriate treatment for many people, of course. But not always, and not if the right surgery is more likely to yield a good outcome.

As long as private insurance is in charge, expect to be steered towards the McDonald's burger, not the soufflé.

Perhaps the only one who cares enough to fight for the extraordinary, above-the-norm care is you -- the patient whose life will be saved by it.

Ask me about my new

"Insurance Insider Secret Contacts List"

********

I know where the Medical Directors are hiding, and I've got their fax numbers!

Happy and peaceful Insurance Warrior-ing,

Laurie Todd
http://www.theinsurancewarrior.com/ (http://www.theinsurancewarrior.com/)
ph: 425 497-1858

ZorroSF

12-13-2008, 03:20 PM

Working in the health care industry I am always amazed at how people with insurance are paying for people without insurance. This is truly one of the bigger reasons why our premiums are so expensive today. I am very opposed to Universal Health Care but, something drastic has to take place as there are now 46 million people uninsured in America today and growing every day.

I am more supportive of requiring everyone to have health care insurance. This would cause the costs to go down across the board as we would not be forced to pay for people who do not have insurance. Make the contribution towards their family policy determinate on the amount of their family income.

This solution could work as it requires us to be responsible for ourselves. There needs to be some healthy initiative incentives to get people take better care of themselves. The policy amount is determined by the income level of the family but, also tied in to their lifestyle choices. Obesity, drinking and drugging, lack of exercise, smoking, etc. would cause premiums to increase to make up for the loss of revenue associated for taking care of people who make unhealthy lifestyle choices.

Terry Newton

I was very surprised by your response, but I could understand it because you are coming from a drug dependence angle. I have to totally disagree with you. "I got mine you get your's" attitude is what created this situation in the first place. It's what even created the Wallstreet crash of 2008. No regulations and no accoutability on behalf of the private medical industry to rake in unlimited cash is what has created these flopsided patient costs. Not the poor or the irresponsible one's.

Most people undergoing spine surgery, much less orthopedic surgery have been taking care of themselves. It's the insurance and medical industry that have been gaming us. It's not the fault of the poor that surgery is so expensive. That's just a false fact that the insurance industry is pushing to get away with stealing money from the insured and the taxpayer.

If you want to solve the medical cost problem in this country you have to look overseas at other industrialized countries and learn from their sucesses and mistakes. Most DO REQUIRE insurance on all citizens, but that is not the reason for high healthcare here since local municipalities in the USA cover hospital and doctor expenses that aren't paid by the patient. That means the hospitals and doctors are getting paid through local taxes. Since state laws require hospitals to take in patients, the hospitals in return require that the local city pay for unpaid bills.

http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/

The Swiss example shows that universal coverage is possible, even in a highly capitalist nation with powerful insurance and pharmaceutical industries. Insurance companies are not allowed to make a profit on basic care and are prohibited from cherry-picking only young and healthy applicants. They can make money on supplemental insurance, however. As in Germany, the insurers negotiate with providers to set standard prices for services, but drug prices are set by the government.

Harrison

01-20-2009, 12:40 PM

The Insurance Intelligencer

Usual, Customary and Reasonable

The phrase "Usual and Customary" has been in the news recently. "Usual and Customary" nets health insurers billions of dollars every year. It puts dedicated medical providers out of business. It costs patients hundreds of millions of dollars that they never expected to spend.

The tables were turned last week. The Attorney General of New York took a long, hard look insurance company reimbursement policies, and "Usual and Customary" just cost United Healthcare fifty million dollars.

Remember, the entire insurance industry runs on words. Words with secret meanings. Words that the insurance company uses to shift costs from themselves to you, and to your doctor. Words which are carefully crafted to make you not question.

What words do health insurers use to save money BEFORE you get your treatment? They deny the treatment, by deploying the words "Experimental/Investigational." Most patients believe that the insurer has some type of proof behind these words. Further, they have no idea how to prove that the lifesaving treatment which they need is NOT experimental. So they give up.

What words to health insurers use to save money AFTER you get your treatment? "Usual and Customary." UCR is a mystery to even the most sophisticated medical consumers.

Let's see how it works ...

A new person calls me with insurance troubles. He needs very expensive out-of-network cancer treatment. I ask, "Do you have a PPO, or an HMO? He replies, "I have a PPO, so I can go wherever I want." I continue, "If you go out of network, how much will they pay?" People invariably reply, "80% (or 70%, or whatever percentage).

Then I ask the quiz question: "80% of what?"

I have asked this question of attorneys, bank vice presidents, college professors. Nobody has ever answered the question correctly.

80% sound like "a lot," doesn't it? No matter how much it is, I won't have to pay much, right? WRONG. Your insurer is not offering to pay 80% OF BILLED CHARGES. They are offering to pay 80% of Usual, Customary, and Reasonable charges.

Wait just a doggone minute? Usual and customary according to WHOM?

The one surgeon who can remove your difficult brain tumor is not contracted with your insurance company. Since you are especially diligent, you obtain an estimate for the surgery plus hospitalization: approximately $100,000. You say to yourself, "OK, I can manage to pay the $20,000 that they won't cover."

You have the surgery, return home to recuperate, and the bills start rolling in. Here is how UCR works. Your insurer deems ten percent of your $100,000 treatment to be "usual and customary." That would be $10,000. They pay 80% of that amount, which is $8,000. Since there is no contract between your insurer and the out-of-network doctor, the doctor is perfectly within his rights to balance-bill you for whatever the insurer doesn't pay: $92,000.

The surgeon who saved your life can either take a huge loss ... or bill you, and look like the bad greedy guy.

You may well ask, "How do insurers determine what is "usual and customary" for all of these surgeries and treatments?"

If you ask your health insurer, they will give one of two answers:

"That information is proprietary (secret)."
"Independent research from all across the industry."

Alrighty then! Independent research!

Guess where the figures really come from? A number-generating company called Ingenix. Ingenix is a subsidiary of ... drumroll please ... United Healthcare!

Makes sense to me. Truly the most brilliant case of cost-shifting ever. Truly the world's worst conflict of interest.

What do these words mean, and why are they so persuasive?

Usual: In accordance with custom or ordinary practice; Normal.
Customary: Based on or established by custom.
Reasonable: Possessing sound judgement; not extreme or excessive.

UCR is the most powerful piece of propaganda that I have ever seen. You couldn't possible dispute the insurer's offer to pay what is Usual, Customary, and Reasonable, could you? Because then you would be abnormal, excessive, and downright crazy.

Who suffers from this massive swindle? The ill and recuperating patient, who believed he was "covered at 80%," who never drilled down to find out what that meant, and who suddenly has to come up with $92,000." And the one who actually did the work, and saved your life -- the surgeon.

You pay more for your PPO. The premiums are higher than the HMO, the deductibles and co-pays are higher. For this, you get an illusion of choice, and the privilege of boing broke if you need to go out-of-network for medical treatment.

Think about it. Patients don't go out-of-network for the fun of it. They go because they are in trouble. Big trouble. Expensive trouble.

Will your entire out-of-network treatment cost more than you could afford to pay in cash? If the answer is "yes," then prepare to write your appeal. In the appeal, you will prove that there is no comparable treatment IN the network, and that the in-network doctors made some very embarrassing mistakes in your case. You will persuade them to sign a contract with your doctor-of-choice, requiring that your insurer pay 90% of BILLED charges.

I do it all the time, and I win them all the time.

**********

If this is news to you, Fight Your Health Insurer and Win should be on your shelf.
www.theinsurancewarrior.com (http://www.theinsurancewarrior.com/)

Happy and peaceful Insurance Warrior-ing,

Laurie Todd

Harrison

02-11-2009, 01:29 PM

Anthem Blue Cross and Blue Shield:
Big, Bad, and Loaded for Bear

My good friend who works for a health insurance company often asks a rhetorical question: "You don't believe that health insurers are the evil empire, do you?"

I never thought about it, until I squared off against Anthem Blue Cross and Blue Shield.

Anthem is big

March 2007: A patient in California tells me that Blue Cross of California has been gobbled up by Anthem BC/BS.

What is going on here?

Anthem is bad

July 2007: I am in Calfornia for a speaking engagement, and I pick up the Hayward newspaper. I see the following headline:

"California didn't try to collect Anthem Blue Cross fine."

In 2006, the California Department of Managed Healthcare levied a fine of $200,000 against Anthem for one unlawful case of "recission." Here is how recission works. When you become expensive (i.e., get sick), Anthem's recission experts get to work. They go back to your original application, and go over it with a fine-tooth comb, looking for an offense/glitch/mistake that would enable them to cancel your coverage.

Anthem did this to 1,770 insured and ill people between 2004-2007, and California imposed an additional fine of $1 million. California has never collected any of this money.

The intrepid reporter from the Hayward Daily Review asks the Director of the Department of Managed Healthcare, "Why haven't you collected any of this money?"

The Director replies that Anthem has the right to contest every one of the 1,770 cases in court. Since Anthem has so many recissions, his department will be tied up in the courts for many years, and no fine will ever be collected.

If you become big enough, you will overwhelm the law with the very weight of your offenses. In other words ... you win.

Anthem is loaded for bear

In September 2008, a very nice gentleman called me from Virginia. He wanted to get to Dr. Sugarbaker for the same lifesaving surgery that I had in 2005.

I went looking for successful lawsuits against Anthem. How did they win, what did they prove, what words did they use?

I happened across Dardinger vs. Anthem of Ohio. I found plenty of language to use. I also found the story of Esther Dardinger.

This was a tort case, on behalf of the estate of Mrs. Dardinger. Yes, the plaintiffs in these types of lawsuits are usually dead. She was forty-nine years old, and she suffered from brain cancer, which had metastized from the breast. Her doctor, who was Director of Neuro-Oncology at the local medical center, recommended that she undergo four treatments of IAC (intra-arterial chemotherapy), which delivers the chemotherapeutic agent directly to the brain.

Anthem approved, and paid for the first three treatments. These treatments dramatically shrank the brain tumors, and improved her symptoms.

When it came time for the fourth treatment, Anthem denied it. All of a sudden, this treatment had become "experimental."

The patient and her husband had no idea what to do. Appeals were filed by doctors, lost, shelved, ignored. All of the interested parties were told to "wait for our letter," "wait until we decide," "wait for our call." This went on for three months.

The final denial letter arrived two days after Esther Dardinger died.

Anthem's position during the trial? "The only mistake we made was paying for the first three treatments." How must it have felt for the widower to hear that?

The court threw the book at Anthem for their "reprehensible" behavior, and slapped them with a $20 million fine.

Apparently, Anthem didn't learn from this case, because they were about to beat me with the same big stick.

Anthem spits in my eye

I will spare you the gothic novel that was my Anthem BC/BS of Virginia case. Suffice it to say that for two weeks they had a half-dozen of us on the ropes, losing sleep, writing letters all night long.

I have won forty-three appeals by assuming that health insurers will pay if I can prove that ...

They have paid for it twenty-two times before.
Their in-network doctors have no expertise with this disease.
Their in-network doctors have made mistakes which could be fatal.
Hundreds of peer-reviewed articles document good outcomes.
I can find all of their most secret, highest-level insiders -- and their fax numbers.
... they will pay.

Not Anthem. In this case, they adopted a posture of, "We will deny all appeals, regardless of the merits. No approvals, ever. Just try and stop us. We spit in your eye."

First, Anthem tells my helpee that he has to go to an unqualified surgeon who is "in-network." That is standard.

Next, Dr. Sugarbaker's office finagles with Anthem until they approve the hospital ($150,000), but not the surgery ($25,000). This step is standard, and it always gives me a wry chuckle. What use is the hospital without the surgery? Didn't anyone tell Anthem that he is going to the hospital FOR a surgery?

At this point, I deploy the seventy-eight-page appeal, to get Anthem to approve the surgery, and sign the single-case contract with Dr. Sugarbaker's office. Here is where Anthem veers completely off the usual path. Instead of responding to the mountain of proof with a willingness to negotiate, they punish us by taking away the approval for the hospital. The patient is worse off than he was to begin with; he now has nothing.
Anthem justifies "taking back" their approval in two ways:

"We suddenly figured out that this treatment is experimental."
"We never approved it in the first place." (Even though we have copies of the approval letter.)

We supply cases where Anthem paid before. Anthem says that none of our precedent applies, because they those cases were in different states. So, Dr. Sugarbaker's office finds a case in Virginia where Anthem paid. Anthem say that they need "more cases in Virginia." They won't say how many cases would add up to an approval.

Dr. Sugarbaker's office finds two more Virginia cases where Anthem paid. Anthem says, "We will do everything in our power to find the differences between these cases and the current case."

Does this look like a good faith effort to provide safe and effective lifesaving treatment, or a no-holds-barred attempt to deny?
We kept on writing, they kept on spitting.

Finally, Ilse at Dr. Sugarbaker's office managed to maneuver Anthem into reinstating the approval for the hospital. The patient had to pay out-of-pocket for the surgery.

People say, "How can they do this? Can't you sue them?" Sure, go ahead and sue them ... but you probably won't win unless you're dead. Or should I say until eight years after you die, because that is how long it will take to wend its way through the courts.

Did they persist in denying this treatment, with no good reason for doing so? Was it deliberate? Was it evil? I leave it for you to judge. All I know is that it almost did me in.

The patient in question had his surgery with Dr. Sugarbaker today. I think back, as I always do, to my own surgery in 2005. I trust that, in four years, he will be as healthy as I am today. That he will be transformed by the experience, as I was. And that he will know, as I do, the sweet satisfaction of helping and being helped.

Happy and peaceful Insurance Warrior-ing,

Laurie Todd

Give a copy of my book to someone you care about today.
http://www.theinsurancewarrior.com/ (http://www.theinsurancewarrior.com/)

Harrison

03-07-2009, 06:29 PM

Listen up MIDWESTERNERS!

The Insurance Warrior is Coming to CHICAGO!

May 15-16

********

http://www.theliversymposium.com/ (http://www.theliversymposium.com/)
Registration is only $75 for the entire conference. I will be giving two presentations, and a Winning Appeal Workshop.
Any questions, contact laurie@theinsurancewarrior.com (laurie@theinsurancewarrior.com)

The Insurance Intelligencer - 3/9/09

The First Three Things to Do

Over the past four years, I have talked to hundreds of people who discover, one day, that their health insurer doesn't plan to pay for their treatment. There are many reasons for this, as health insurers have developed countless ways not to pay.

By the time people get around to calling me, they have usually galloped off down the wrong path, and lost at least one appeal. They have no concept of why the insurer is really denying, or how to meet that denial head-on. They try to prove that their treatment is not "experimental," without having any idea what the insurer means by this.

They are fighting the wrong battle, with the wrong ammo, on the wrong hill. Meanwhile, the insurer is rolling right over the top of them, on to victory, with not a dent in their armor.

What People Do

When the insurance won't pay, people call for help. Who do they call?

The insurance company
The Insurance Commissioner
A lawyer
The media
Call the insurance company for help, because the insurance company doesn't want to pay? They are going to make themselves pay? I believe that people pursue this non-sensical approach because they are afraid, and they need to believe that the insurer is there to help them. Our lives are on the line, and we want to believe that we are in caring hands with our insurance company.
The name of the insurance company will make you feel safe -- "Neighborhood Health Golden Rule Care Choice United Insurance Company." The titles of the employees will make you feel all warm and fuzzy -- "Customer Care Rapid Response Resolution Team." Their job is to calm you down, make you wait for their letter, and to keep you away from decision-makers at all costs.

You aren't safe. They aren't planning to pay, and you won't move them one inch. All that you will do is raise your blood pressure.

Call the Insurance Commissioner? First, all most Insurance Commissioners do is take a complaint, and get back to you in a few months, saying that they looked into it. Insurance Commissioners have no power, health insurance companies laugh at Insurance Commissioners.

Call a lawyer? Guess why lawyers aren't interested in denial of care cases ... there is no money in it. No damages. If you win a denial of care case, all you get is your treatment.

Will the media intimidate an insurer into paying for your treatment? It would have to be a pretty massive media blitz, including the national news and the Today show. Is your insurance company going to be reading your local paper, or watching the local news, and suddenly decide to pay? Could happen, has happened. However, there is so much bad press out there about many of our insurance companies. It doesn't appear to bother them in the least. What then should you do?

ONE: Find the Medical Policy Statement

When the insurer denies your treatment, you need to know what is their official policy about it. Once you have the Medical Policy Statement in your hand, you can start to disprove it.

You think that you understand your coverage (i.e., your contract with the insurance company), because you have read your benefits booklet. Wrong. That contract is modified and limited by a body of hundreds of Medical Policy Statements, which are sometimes called Treatment Guidelines. You may think you have a certain amount of coverage, but you have no coverage if you happen to need one of the treatments referred to as "investigational" or "not medically necessary" in the Med Policies.
Where do you find the Med Policies? On the insurance company website, under the section for physicians and medical providers. Yes, you have graduated. You now look where the doctors look.

Each Med Policy states their position on a treatment, then offers ten or fifteen sources to back up their position. If you don't like their position, start digging into these articles/associations/groups etc. that they use as proof. You will be amazed to see that most of it is useless, outdated, doesn't prove their point, or is generally a carton of hot air. Drill into the Med Poliicies, because it is these documents that the insurers are using to deny your treatment.

TWO: Study the definitions

Do the benefits booklet and the Med Policies constitute your complete contract? No way! Your coverage is also limited by the "definitions." You thought that those definitions at the back of the benefits booklet were just there to help you decipher the insurance lingo? Joke's on you, these definitions are the pillars that there denials stand on. And the only way to reverse the denial is to knock the pillars out from under them.

If your treatment is denied as "experimental," please don't run around like a chicken, trying to prove that the treatment is not experimental based on what YOU think it means. Find the definition, argue that your treatment meets and exceeds every requirement, and make it the centerpiece of your appeal.

THREE: Understand the appeals procedure

People often call me saying, "I lost my first two appeals, what should I do?" I ask, "What further appeals procedures are available to you?" Invariably, the say, "I don't know?"

It's your appeal, you've lost two of them, and you have no idea what your insurer's appeal procedures are?

If you plan to approach this battle strategically, the first thing that you need to know are the rules of engagement.

Whatever you do, don't simply sit down and start writing an appeal. Insurance Warrior-ing is a new profession for you. That means that you don't know how to do it yet. If you decided to become a brain surgeon, would you just march into an operating room and start hammering on somebody's head? First, we study. Then, we research. Next, we plan our strategy. Then, we write our appeal.

Put yourself through basic training, learn the rules of engagement, choice the right weapons and learn how to use them. Know your enemy. Keep a cool head. And you will emerge victorious.

Happy and peaceful Insurance Warrior-ing,

Laurie Todd

P.S. If any of this is news to you, perhaps my book should be on your shelf.

Harrison

05-26-2009, 10:46 AM

LAURIE'S NEW BOOK IS HERE!
Hot off the presses!
It's a CD!

"The Sample Appeal: More Insurance Warrior Wisdom"

Check it out:
www.theinsurancewarrior.com/thebookandthecd.html (http://www.theinsurancewarrior.com/thebookandthecd.html)

****************************************

All Plan Language is Misleading

I recently had a call from a newspaper reporter, asking for information for an article about "misleading plan language."

The reporter was not looking for my opinion. She assumed that I offer a service sorting out people's medical bills -- a type of patient advocate, or a reimbursement specialist. She wanted me to provide the names of several patients who had gotten into trouble because of "misleading plan language." Her request made me reflect on both what I do, and on what role misleading plan language plays in the larger world of health insurance.

First, let me say that I do not offer a service. I speak, I teach, I write on insurance topics. I fight the occasional appeal, but only if it is difficult, compelling, and lifesaving.

Medical bills give me a big headache; I want no part of them. That is why I write powerful appeals up front -- so that there will BE no medical bills.

The reporter's question was based on the assumption that a benefits booklet is a good faith effort by the insurer to explain your coverage, and the only problem is that a few phrases might be misleading.

People, please. I am asking for a paradigm shift. The entire purpose of a benefits booklet is to mislead, and all plan language is misleading.

What is a benefits booklet?

My plan documents?
A summary of my coverage?
An explanation of what my insurer will pay?

Think again. The benefits booklet explains the medical services covered by your insurance plan. It just doesn't include all of the circumstances under which they will NOT cover them.

In my opinion, that is misleading.

What is the purpose of a benefits booklet?

To make you feel well-covered and financially secure, while shifting more and more of the medical expenses to you.

It's a tricky business, one which requires very misleading language.

Last year, a friend asked me to review three different insurance plans. She needed to decide between them, and she figured that the Insurance Warrior could shed some light on the situation.

It has been twenty years since I chose a health insurer, or studied a plan summary. Twenty years ago, benefits booklets were pretty straightforward. As I examined these three insurance plans, I was amazed to see how complex, opaque, and generally misleading such insurance documents are nowadays.

Dig a little more deeply into any plan documents, and you will see all of the ways of not paying that are built into the plan language. Powerful denial words are mixed in with harmless coverage words.

I know a lot about how insurers use words to deny treatments. I was amazed at how insurers are now using the same words up front -- to lay the groundwork for not paying later.

They give with one hand, and take with the other.

How does the language mislead?

The biggest-ticket item in anyone's insurance plan is prescription drugs. Let's look at the Plan Summary of Acme Insurance, and see how the language misleads you into thinking that you have coverage, when you don't.

The misleading language starts with the name of the plan: Acme Insurance Comprehensive Plan. Sounds like it covers just about everything, doesn't it?

The Comprehensive Plan is the most expensive. One of the extra benefits that you are paying for is prescription drug coverage. And yet, when you put all of the language together, you are not covered at all. What could be more misleading?

Let's count the ways in which Acme shifts the prescription drug costs to you:

You have a yearly maximum of $2,000 -- just for prescription drugs. Those of you who have had cancer know that you will use that up in a week. Avastin, a cancer drug, costs about $13,000 per month. Erbitux, a monoclonal antibody also given for cancer, costs in the neighborhood of $62,000 per month. You are exposed, you have no coverage.

In order for Acme Insurance to pay for it, a drug must be on the "formulary." Guess which drugs are not on the formulary? The most expensive ones, and the most commonly prescribed ones.

How can you know ahead of time what illness you may get, and whether the drug that treats it will happen to be on the formulary? The formulary shifts the largest burden of drug costs to you, while giving the illusion of coverage.

In the fine print, Acme states that they have a "closed formulary." Do you know what that means? On the Acme website, it says, "The closed formulary provides value." Talk about your double-speak. In a closed formulary, the insurer only pays for the most inexpensive, generic form of any drug. Value indeed -- to the insurer, not to you.
The drug must be on the formulary, you only get a pitiful $2,000 per year. Guess what else? Acme only pays 50% for any and all prescription medications that they do cover.

But it gets worse. There are three "tiers" of drugs. For the more expensive drugs that Acme has generously included on their formulary, they don't pay even 50%. For these "first tier" drugs, they pay only 30%.

Oh, and one more thing. Acme can deny any and all prescription drugs that you might need, whether or not they are on the formulary. All they have to do is call them "not medically necessary." Not medically necessary according to whom? According to the Medical Director of the insurance company.
Sometimes I wonder why they bother. Why don't they just say, "We don't cover prescription drugs"? Because people want prescription drug coverage. Or at least something that looks like coverage.

Know that all plan language is misleading. But also know that all of the forty-four appeals that I have won have been for totally out of benefit, not covered, out of plan services. And yet have always paid, if I lean on them in just the right way.

When it comes to health insurance, everything is negotiable. But only if you see through misleading plan language, and turn it to your advantage in your appeal.

Happy and peaceful Insurance Warrior-ing,

Laurie Todd

Harrison

06-25-2009, 10:45 AM

The Insurance Intelligencer
6/25/09

What is the matter with health insurance?

I can put it in three words: Insurance. Drives. Care. A private, for-profit corporation gets to decide whether or not they will pay for lifesaving treatments, which are always astronomically expensive.

Make no mistake about it -- health insurers are for-profit businesses, no matter what they call themselves. It is the job of a business to minimize operating expenses, and to maximize profits. That is what a business does.

We would not expect any other business to care about our lives, or about our quality of life. We would not agonize over the fairness or unfairness of any other business's decisions. Why are we so shocked and disappointed when we discover that Acme Insurance is not the least bit moved when we tell them, "But, without this treatment, I will die"?

Because of the propaganda.

I am not outraged that a bureaucracy makes unfair decisions, or that a business doesn't value lives above profits. That's life in the free-market economy. What does rile me up is the vast body of propaganda, designed to make us believe that they do.

The website with photos of happy, healthy insured people. Riding their bicycles, gazing up at the name of the insurance company: Neighborhood Healthy Choice United. You know, the insurance company that will refuse to pay for your child's brain surgery. The same insurance company that, if you need out-of-network treatment for breast cancer, will bill you for an extra $200,000 beyond what they consider to be "reasonable and customary." Some choice.

We have lived under this insurance-driven system for forty years -- so long that we accept it without question. We cannot imagine any other way.

In what world is it acceptable for a health insurer to pay for a lifesaving treatment for a hundred cancer patients, then to turn around the next day, and deny the same treatment as "Experimental"?

In what world is it acceptable for a health insurer to have the sole, unfettered power to decide how much they will pay for medical treatments? To keep this payment information secret. And to generate the numbers themselves.

In what world is it accepatable for a health insurer to deny a cancer patient the one treatment proven to prolong his life -- a treatment which costs $50,000 -- while spending $1.5 million on routine in-network treatments and surgeries, with no scientific proof that they will prolong his life, or give him any clinical benefit whatsoever?

Not in my world.

Let's see a few of the ways in which insurance drives medical decisions.

Your doctor: The gatekeeper

Your Primary Care Physician looks like a doctor. He wears a white coat. He asks the questions that doctors ask.

As you sit in his office describing your symptoms, you assume that Dr. PCP's job is to discover what is wrong with you, find the best treatment for your condition, and order the treatment for you.

Think again. The Primary Care Physician's job is to be the gatekeeper. In other words, to control access to medical services. A job which fulfills the primary goal of a business, which is to control operating expenses. Sounds like an insurance job, not a medical job.

If the best treatment for you does not happen to be offered in the insurer's network, it is not his job to find it, to offer it, or even to know about it.

This is one of the deeper problems of insurance-driven treatment.

I have a late-stage cancer. There is one out-of-network treatment that could rid me of the cancer, and give me a 70% chance of non-recurrence. This treatment has been performed, studied, proven for thirty years. In what world is it acceptable for the Chief of Oncology to say to me:

There is no treatment for your disease.
If there were a treatment, they wouldn't pay for it.
If you had this treatment, you would be disabled.
I wouldn't send my mother for this treatment.
Ignorance? Acceptable. Because, in the insurance-driven world, if we don't have it in-network, it doesn't exist.

Lies? Acceptable. If he champions an out-of-network treatment for me, it will be a monumental hassle for him, and they won't pay in the end. My current local doctor is smart, diligent, respectful, and hard-working. However, even he is infected with insurance-think. Whenever I bring him new material to read about the treatment which saved my life in 2005, he says, "Of course, your cancer is so rare ... we won't see any more cases of it."

The horrifying presumption is that it is our job as insurance medical providers to treat the lowest common denominator of diseases and conditions. Why would we go out of our way to learn about a "rare" disease?

I belong to a very small HMO. I am not privy to medical records. I personally know of ten members of the HMO who have been diagnosed with my type of cancer. One of them was the wife of an HMO doctor. She was mistreated there for three years, until a friend happened to tell her about me. I talked to the patient, and to her husband the rheumatologist. They called my expert surgeon, but it was too late -- her disease was too advanced. She has most likely died by now.

This disease -- appendix cancer -- may have been rare back in 1962, but it is not rare now. However, my doctor will always see it as rare. Why? Because there is no treatment available in the network.

Even if you have the most common cancers, the best, most effective, most cutting-edge treatments may not be available in-network. As a matter of fact, they probably won't be, as insurance companies are very slow to approve new treatments. Like thirty years slow. Will your doctor know about them? Will he tell you about them?

What treatments your doctor offers are driven by insurance.

Denials and reimbursement strategies: How they shape medical care

We know that denials allow the insurer to not pay for that treatment, in that particular case. Of all people who receive insurance denials, only one-half of one percent ever appeal the decision.

If the patient is ambitious enough to appeal, and get the denial reversed -- still no problem for the insurance company. They will simply reduce reimbursement on the other end. Once the lifesaving treatment has been performed, Acme Insurance will delete codes, bundle codes -- whatever it takes to reduce reimbursement to pennies on the dollar.

Don't worry about Acme Insurance. Even if you make them pay for non-routine payments, they won't pay much.

We see that the insurer has many ways of reducing their operating expenses: Delay, deny. And, when you have to pay, don't pay much. Reducing expenditures is a perfectly natural practice for a for-profit business.

However, there are larger implications. Insurance drives care.

There is a perfectly good treatment for liver tumors called Y90 radioembolization. It involves introducing radioactive microspheres directly into the liver, via the hepatic artery. This treatment improves symptoms and prolongs life for people with primary liver cancer, and liver metastases from breast cancer, colon cancer, ocular melanoma, and neuroendocrine tumors.

Recently, a large medical facility had to stop offering this treatment for most cancers. Insurers vigorously denied it, or paid so little for it that the provider was losing about $10,000 per treatment. They couldn't even cover the cost of the microspheres.

Consequently, people won't be getting this treatment anymore at this medical center. Soon, other medical centers with have to stop offering it, too. Unless, of course, they bill Medicare enough to make up for the appalling shortfall from private insurance.

Is this acceptable to you? What if your mother needs this treatment, or she will die? If she is denied, I can write an appeal for her. However, if the treatment is no longer available, there is nothing that I can do.

What would the Insurance Warrior do?

I usually refrain from pontificating about the larger insurance issues. However, more and more people are asking, "What would you say, if Barak Obama asked you what to do about health insurance?"

First, Barak Obama should ask me about health insurance. Not only have I thought deeply about these issues, but I see up close and personal how insurance company decisions play out in the lives of real doctors and patients -- including myself.

As it stands now, the insurance company gets to decide whether or not we will get the astronomically expensive lifesaving treatments that the insurance company is going to have to pay for. This is insane.

Peer-to-peer reviews are performed by the same Medical Director of the insurance company who denied the treatment in the first place. He is not a peer, and it is not a review. The last independent review that I got mixed up with was for a technologically complex cancer surgery. The "independent review organization" was a chiropractor with a post office box in Lubbock, Texas. With an independent review, there is no accountability, no input, no recourse, and no oversight. They could uphold 100% of insurance denials, and nobody would ever know.

No matter how much you pretty it up, and try to give the illusion of due process -- this is the world's worst conflict of interest.

I would take both the research about which treatments to offer, and the decision on when to approve them -- out of the hands of the insurance company. Most of the treatments denied by insurance companies have more scientific proof of their efficacy than the treatments routinely offered by the insurance companies. They have no track record in making good decisions about treatments, it needs to be taken out of their hands.

A truly independent entity would be tasked with finding the treatments most likely to give a good outcome -- regardless of whether the doctor or facilty was contracted with anybody's insurance company.

Then, so that all doctors don't quit the profession, and all medical facilities don't go broke -- I would task my independent entity with setting fair reimbursements for medical services. I would also outlaw fraudulent and deceptive practices designed to unfairly reduce reimbursement.

We don't expect insurance companies to operate at a loss. Why should we expect the medical providers who are saving our lives to do so?

Give Barak Obama a call. I am eager to talk to him about health insurance.

Happy and peaceful Insurance Warrior-ing,
Laurie Todd
********

My new book is here! It's a CD!
It answers all of your questions about how to write an appeal!
It includes a sample appeal for you to edit and use!

"The Sample Appeal: More Insurance Warrior Wisdom"

Find the new CD/book at www.theinsurancewarrior.com/thebookandthecd.html (http://www.theinsurancewarrior.com/thebookandthecd.html)

SAVE $5 on the book/CD set.

Harrison

07-20-2009, 01:52 PM

The Insurance Intelligencer
7/20/09

Calling your insurance company: The Mad Hatter's Tea Party

Ken recently bought my book and CD. He has studied these materials, and he is writing an insurance appeal.

Ken told me that he couldn't find any executives at Acme Insurance to copy on his appeal. I searched and found the names of the President, Medical Director, and Vice President of Quality Assurance, and sent them to him. I explained how to google, then told him to go out and find personal contact information for them, so that he could fax his appeal to the Medical Director in the middle of the night.

The next day, Ken emailed, "I called Acme Insurance, and they would give me the Medical Director's personal fax number."

Ken was doing a lot of work, and paying attention to the details. However, he was missing the whole point behind the details.

It is the insurer's job not to pay. And your job to make them pay.

The insurer is not going to help you win your appeal. They aren't going to be eager to give information over the phone that will help you to win your appeal.

Back to Basics

Laurie's Rule #1: The only reason to call your insurer is to find out where to write to.

Have you ever tried to solve anything with your insurance company by calling them on the phone? I will tell you what happens:

They won't give you their last names.
If somebody gives you a call-back number, it won't work.
Each person you talk to has a different answer to your question.
You won't get any higher on the food chain than Customer Service
Excuse me ... they don't call them Customer Service anymore. They call them "Customer Care," because they do want you to know that they care.
Customer Care won't be able to find a copy of your contract, and they won't know how to find your benefits booklet. They will be eager to put you in what I call "Waiting Mode." Wait for our call, wait for our letter, wait for our decision. Wait as long as we tell you to wait. Wait until you are either dead or all better, and we don't have to deal with this pesky problem anymore.

You will talk to many people. My favorite case of Insurance Phone Madness comes from Florida. Camille was fighting hefty hospital bills after the fact; this is called a "grievance." Sort of makes us sound like whiners, doesn't it? Just pay your bills, and stop giving Acme Insurance all this grief! She kept a list of every employeee that she talked to at Acme Insurance. What she asked, what each one said.

Camille talked to forty-eight people at Acme Insurance. She was no closer to winning her case than she was to begin with; she had gotten nowhere.

The only reason why talking to forty-eight people wasn't a complete waste of time? Because I took the entire list, and made it the centerpiece of her written grievance. I quoted each of the forty-eight people -- each telling her how they were going to solve her problem, each not doing anything. Each making promises, each breaking promises.

The entire Mad Hatter's Tea Party of phone calls looked very embarrassing in her grievance letter. It took Acme a couple of weeks, but they decided to pay.

Do they do this on purpose?

People often ask me, "Do insurers discourage, dissuade, dissemble, delay and deny us on purpose?

I don't know. And it doesn't matter. All that matters is that you not waste your precious energies on the phone with the insurance company. Do your research, line up your facts, send your appeal to the correct decision-makers.

By doing this yourself, you do not engage in the losing exercise of calling your insurance company on the phone.

How do I find the Medical Director

And so, we end where we began. How do we find personal contact information for the Medical Director of Acme Insurance?

Acme Insurance will do everything they can to keep his name and contact information from you. He is the highest medical decision-maker at the insurance company! He must be protected from the likes of us -- insured people, with our nasty, troublesome issues!

Here are some real examples of what Customer Service says, when you call on the phone, and ask about the Medical Director:

We don't know who we work for.
We have no Medical Director.
The Medical Director is on vacation.
We dare not speak his name.
People. They don't want you to have this information. Google the Medical Director, and find him yourself. Here is how I do it:

Study the Acme website. Be persistent, spend an hour if you have to. Look for the "Leadership Team." If there is a search feature, search for "executives," "medical director," "or "chief medical officer." Get a name and title.
If you can't find him on the insurer's website, google "medical director acme insurance 2009," "medical officer acme 2009," or "vice president acme insurance 2009." I include the current year, so that I don't have to wade through a dozen past medical directors.
When you have the current Medical Director's name, google, "john smith acme insurance phone," "john smith acme fax," or "john smith acme insurance email." You may have to sift through six pages of search results, but you will find your man.
If Acme Insurance goes to that much trouble to keep you from the President, the Medical Director, and the Vice President of Quality Assurance ... you know that access to them is pure power.
That is why I invite you to be as relentless as I am, to find their personal information, and to fax them a copy of your appeal.

Happy and peaceful Insurance Warrior-ing,

Laurie Todd

Harrison

07-29-2009, 02:27 PM

Laurie Todd, the Insurance Warrior, is going to be on live radio tomorrow (Thursday) morning. That's July 30, from 8:00-8:30 a.m., Pacific Time.

Anybody anywhere can listen to me live on the station's website:

www.chatwithwomen.com/pages/live.php (http://www.chatwithwomen.com/pages/live.php)

Or, if you live in the Seattle area, you can listen at KKNW 1150AM.

*********

All health insurance is good, until you need something that they do not want to pay for.

As insurance premiums skyrocket (mine just went up 17%), and the medical care that they cover plummets, more and more of us will find ourselves facing an insurer who doesn't want to pay.

Treatments are denied with words, and denials are overturned with words. I have figured out how to turn insurance words to our advantage.

I invite you to share this with everyone you know who has health insurance.

Laurie Todd
www.theinsurancewarrior.com (http://www.theinsurancewarrior.com/)

Harrison

08-30-2009, 03:11 PM

The Insurance Intelligencer
8/31/09

The $3.7 Million Man

As I go forth to speak to general audiences, people make remarks about the state of healthcare.

I heard this one last week in the farm belt of Ohio:

"The problem with healthcare these days is greedy doctors."

Treatment denied

On August 5, I received a call from Tina in Michigan. Her husband Michael had been diagnosed with metastasized abdominal cancer. He needed the same tried, proven lifesaving surgery that I had undergone four years ago.

The facts of the case:

The surgery was denied because it was "out of network."

Tina has a self-funded plan. This means that her employer gets to approve or deny Michael's treatment.

The employer is St. John Health. which is a non-profit Catholic hospital.

The insurer is Blue Cross Blue Shield of Michigan, which is also a non-profit.
After the treatment was denied in June, Tina and Michael left the appeal to their doctor. He wrote a one-page letter which said, "I am the treating physician. This is the patient. In my professional opinion, the patient needs this treatment."

The doctor's appeal was denied. A second letter was on the way to the employer/insurer, to launch a second appeal. When Tina called me, the employer's position was: "We won't consider this second appeal until August 24, because the Regional Appeals Committee doesn't meet until then."

Michael's surgery was scheduled for August 20.

I said, "Stop that second appeal. With a self-funded plan, you only get two appeals. After that, it's the Federal District court for you -- good luck with that. Stop the presses, we are going to write a proper appeal."

How much does the CEO make?

When I take on a case, the first thing that I do is to find the highest-level executives of the insurance company -- and of the employer, if it is a self-funded plan. Names are power, access is power, personal contact information is power.

I found the top executive at St. John Health, the Catholic non-profit hospital. In the process, I discovered that there is a higher authority. I am not referring to a divine power, but to Ascension Health Ministries. The mission of Ascension Health Ministries: "We commit ourselves to serving all persons, with special attention to those who are poor and vulnerable." The highest-level executive at Ascension Health Ministries is Anthony Tersigni. Last year, Anthony Tersigni earned $3.7 million. Ascension Health Ministries closed three of their less-profitable hospitals in inner-city Detroit during 2008.

The motto of Ascension Health Ministries? "Healthcare that leaves no one behind." Tina Beitel has worked for St. John Health for nineteen years. They must have missed someone, because they were about to leave her husband behind -- by denying the only treatment that could save his life. Next, I went looking for the head of Blue Cross Blue Shield of Michigan. Blue Cross Blue Shield of Michigan is also a non-profit.

BC/BS of Michigan raised their group rates this year by 22%. They applied to raise the rates on individual policies by 56%. The president of BC/BS of Michigan is Daniel J. Loepp. His total compensation last year was $2.9 million.

In the process or writing and winning forty-four lifesaving appeals, I have developed a high appreciation for the absurd. However ... the irony of this one made my teeth ache.

My goal was to sit here in Seattle, in my worn-out pajamas, and to craft a document that would have Anthony Tersigni running for his checkbook.

How much does the doctor make

The doctor in this case is the surgeon who brought me back from the brink of death four years ago; his name is Dr. Paul Sugarbaker. He has performed over 1500 of these twelve-, fifteen-, twenty-hour surgeries. He has published over seven hundred medical journal articles documenting every aspect of this treatment -- including his outcomes -- over a period of twenty-nine years.

Dr. Sugarbaker pioneered the surgical techniques whereby the surgeon removes every bit of tumor down to 2.5 mm. Then, he treats the remaining microscopic cells with heated intraperitoneal chemotherapy for two hours, making sure that every surface is contacted.

I had metastasized appendix cancer. This same treatment could achieve exponentially better outcomes for people with colon cancer and ovarian cancer. People often ask, "Why aren't more surgeons learning how to do this? Why don't more surgeons want to do this, if it saves more lives?" Why? Insurers hate to pay for it. Hospitals do not like to book such long surgeries, because four five-hour surgeries are more profitable than one twenty-hour surgery. Besides, who would want to work that hard? A surgeon who performs twenty-hour surgeries for thirty years will eventually look like Dr. Sugarbaker -- stooped, with a visible "widow's hump," and permanently listing to one side.

A surgery of such magnitude requires a long hospital stay, with expensive post-operative care. The only thing to be gained from it is better outcomes for patients.

Dr. Sugarbaker is either at the hospital, or out teaching and demonstrating surgical techniques -- all week, every week, sixty hours a week. He rides a bike to work, he has a small office in the doctor's office building, his minimal staff work tirelessly to get insurance companies to pay for this treatment.

How much does Dr. Sugarbaker charge for performing this grueling surgery? $25,000.

And, even when insurers do grudgingly agree to pay for it, they have many ways of reducing reimbursement after the fact. Although Dr. Sugarbaker may bill $25,000, he never actually receives $25,000. Believe it or not, there are bean-counters in an insurance company office who review the surgeon's bill, crossing off line items as "not necessary." When the deleting and bundling of codes is done, he has received as little as $400 for one of these surgeries.

Who would want such a life?

********

Anthony Tersigni, $3.9 million. This equals one-hundred fify-six grueling twenty-hour surgeries, at $25,000 per life saved.

I have never been so motivated to win an appeal. As I researched and wrote, I would say to Tina, "Wait till Mr. Moneybags gets a load of THIS." It took me three days to craft my War Documents. After I faxed and emailed it to all of the top executives in the middle of the night, Tina worked the phones, "Did you receive my urgent, expedited appeal?" Eight days after Tina and I first spoke, the denial was overturned, and the treatment for Michael was approved. That was August 13. They flew to Washington, D.C. on 8/17, and Michael had his surgery on 8/20. Gee, I guess that they really didn't have to wait until 8/24 for the Regional Appeals Committee to meet.

Which brings us back to where we started. Greedy doctors?

If this is all about greed, we will soon have many insurance company CEOs, and no surgeons to save our lives.

Peaceful Insurance Warrior-ing,

Laurie Todd

2cool4U

08-30-2009, 11:19 PM

Excellent article. Last time I checked, physician incomes accounted for about 14% of the total health care spending. That's right, 14%. The rest? Hospitals, insurance companies, home-health care companies...the list goes on. If you cut physician pay by 50%, you would save 7% of the total spending. The savings would be substantial, but there would be no doctors left in practice!

I don't want to reveal my exact costs, and I actually don't know the real final number that my insurance company paid after negotiations, but my surgeon was, in my opinion, woefully under-reimbursed for the 3-hr. surgery and 3 days of post-op visits. And, no, I did not get any professional courtesy discounts. I checked to make sure. In my case, all of the physicians compensation combined accounted for less than 10% of the total cost of the surgery.

That's an astounding number to me.

-tc-

Harrison

09-21-2009, 10:56 AM

9/20/09

The Case of Little Nicholas

With healthcare reform in the news, I see the term "standard treatments" bandied about. Such-and-such a plan will cover standard treatments. As though there were such a thing.

Many of you have seen me unmask insurance company words:

Experimental = It's out-of-network, and we don't want to pay for it.
Not medically necessary = It's out-of-network, and we don't want to pay for it.
Not a covered benefit = It's out-of-network, and we don't want to pay for it.

Rarely are in-network treatments denied as experimental, not medically necessary, or "non-standard." Insurers do not deny treatments based on clinical benefit, geography, or even cost. It's simply a matter of in-network vs. out-of-network.

I have dug deeply into the rationales (scientific reasons) that insurers offer to support such denials. There is nothing there. No science. No clinical evidence for the treatments they do pay for, and no lack of clinical evidence for the treatments they don't pay for.

"Standard treatments" fall into the same Bermuda Triangle as all other insurance company words:

Standard treatments = It's in-network, and thus we pay for it.

Which brings me to the story of little Nicholas ...

Nicholas needs major surgery on his skull

I am often asked, "How do people find you?" Short answer -- in the most amazing ways.

Two weeks ago, I received an email from Heather in Michigan. Heather's six-month-old son, Nicholas, needed surgery on his skull, and her insurer had denied the out-of-network surgeon. One of the mothers in her online support group told her about me. Heather ordered my CD ("The Sample Appeal"), and wrote an appeal herself. That appeal was also denied.

Heather received last month's newsletter, "The $3.7 million man." The insurer in that case was Blue Cross Blue Shield of Michigan. She thought, "That is my insurer. Maybe Laurie will help me." The planets align, and then people are brave and bold enough to reach out to me.

Nicholas had a malformation of the skull called "synostosis." The different parts of the skull are joined together by bands of fibrous connective tissue called "sutures." When babies are born, these sutures are relatively loose and open. The suture lines fuse gradually, as the baby grows. This is an elegant system -- designed to protect the brain, while also allowing it to expand in just the right places.

In approximately one out of every three thousand babies, one or more of the sutures of the skull fuse prematurely. The skull immediately begins to assume an abnormal shape. Pressure on the brain can bring all manner of scary possibilities such as vision problems, seizures, and developmental delays.

In order to fix cranial synostosis, the skull has to be removed, reconstructed, and put back together. With just enough "give" in the right places to allow for unobstructed growth of the brain. This surgery is as complex as it sounds. It is also fraught with danger -- the most common surgical complication being massive bleeding.

A cranial reconstruction by a top-notch surgeon is a work of art.

The insurer wants to keep Nicholas in-network

I asked Heather a few questions about the medical story, and studied her two denial letters. I looked at the qualifications of her surgeon-of-choice. Nicholas' surgery with Dr. Fearon in Dallas was scheduled in ten days.

"The insurance company doesn't want you to go to Dr. Fearon. What do they want you to do?" I asked.

Heather explained to me that her HMO -- Blue Care Network -- wanted them to choose an in-network surgeon for this complex cranial surgery that would determine the quality of the rest of his life.

One of the in-network surgeons proposed an endoscopic "cranial stripping" surgery. The other wanted to completely dismantle Nicholas' entire skull, even though his defect only affected the back of his head. The second surgeon scoffed at the first one, saying, "That technique is way out of date. We haven't done cranial stripping for ten years ... poor outcomes."

In their first denial, Blue Care Network suggested that they look to Nicholas' primary care provider for guidance. The PCP's guidance consisted of, "I don't know anything about either procedure."

In their second denial, BCN came up with three more in-network surgeons, and instructed Heather and her husband to make an appointment with one of them. Time was flying. By this time, Nicholas was six months old -- the outside limit of optimum age to have this surgery.

Two of the second surgeons were cleft-palate experts. The third facility on BCN's recommended list had no pediatric plastic surgeon on staff.

The appeal

I said to Heather, "I will take this case. However, you are going to need to get down in the trenches with me. I know nothing about this condition, nothing about this surgery. I have no proof in my files, and I have no cases of precedent. You are going to have to get me the information that I ask for, call the insurance company and say what I tell you to say. Can you do that?"

Over the next six days, I witnessed the blazing determination of a mother, fighting for her baby.

As for myself, I spent the next three days in my famous worn-out pajamas. I digested scientific articles, websites, book chapters. Then I wrote. Thirty-four pages of persuasive expository prose.

Heather became quite the sleuth -- pressing her case, talking to Medical Directors, finding out what she could about the progress of our appeal. At a certain point, she said, "Isn't this fun?"

I said, "Do you realize that, when you called me three days ago, you said that you were desperate? Now we are having fun, fighting tooth and nail for this surgery."

This is so not about insurance. It is about bringing people through the fire, with spirits up, dignity intact, and sense of humor in full swing.

The best of all possible worlds

Four days after receiving my 34-page appeal document, Blue Care Network decided to pay it all. Never was there more joy at winning an appeal.

The approval came on Thursday, and the family flew to Dallas on Sunday. Little Nicholas had his surgery on Tuesday morning -- a complete success. He is already back in Michigan, sleeping in his own crib.

********

Which brings us back to where we started: Standard treatments. "Standard" is a synonym for "in-network." Babies with synostosis are sent to in-network surgeons who specialize in breast reconstruction, cleft palates, and so on. Some never get to see a pediatric plastic surgeon at all. This would be your standard care. If the surgeon is in-network, he is standard, and he will do.

In writing appeals for all sorts of diseases and conditions, I have learned that there are always one or two physicians who are getting better outcomes. They are often physician-scientists -- publishing many scientific articles, inventing surgical tools, constantly studying, publishing, and improving their outcomes.

They are not likely to be in-network for your insurance. Many of the true pioneers have dropped most of their insurance contracts. Why? The don't need the headaches, and they are weary of the pitiful reimbursement. They are too busy saving lives.

This is your six-month-old son. Is "standard" good enough for you?

Happy and peaceful Insurance Warrior-ing,

Laurie Todd
http://www.theinsurancewarrior.com/ (http://www.theinsurancewarrior.com/)

Harrison

10-18-2009, 07:11 PM

No Happy Dance for Elizabeth :disgust:

This week, I lost an appeal. I want you to know who defeated the mighty Insurance Warrior, so that you can run like the wind from this indomitable beast.

The Insurance Warrior was defeated by ... drum roll please ... a self-funded plan.

********

For years, I have been warning you about self-funded plans. Do you even know if you have one? If you work for a large company -- chances are that you do.

In a self-funded plan, YOU HAVE NO INSURANCE. How is this possible? In a self-funded plan -- regardless of what coverage the plan documents say you have -- your employer has sole and absolute power to over-ride the insurance company, and interpret the plan as they see fit.

Your employer is not an insurance company. Therefore, if you are covered by a self-funded plan ... you cannot speak to the Insurance Commissioner, and you are not protected by state insurance law. Let's say that your state has certain minimum requirements for health care: Insurers have to provide mammograms, a certain level of prenatal care, etc.

Your self-funded plan does not have to do anything. State rules and regulations do not apply. In a self-funded plan, your insurer is free to provide sub-standard care as defined by state law -- because your employer is not an insurance company.

"But I HAVE an insurance company, " You say, "It is self-funded, and the insurer is Acme Blue Cross Blue Shield." Joke's on you. The minute that a health insurer enters into a self-funded plan, it instantly becomes "not-an-insurance-company." Your Acme BC/BS is now, magically, a "third-party administrator."

Instead of being governed by state law, self-funded plans fall under ERISA. That would be federal law, good luck appealing to them. ERISA was designed to regulate employee pension plans. Sneaking self-funded plans into ERISA was the world's biggest gift to health insurers.

Take your employer to court? :mad:

In your self-funded plan ... there is no insurance company. You have no insurance. All you are left with is the whim of your employer. After your employer denies your treatment, your only option is to hire an attorney, and take your employer to court. There are, however, major disincentives to doing so:

Do you really want to fight your employer in court, after spending a year fighting cancer? Most people will never take their employer to court. Employers and insurers know this.

In an ERISA case, the court is not allowed to award damages. If you win your case, all you get is payment for the treatment that they should have paid for to begin with.

In an ERISA case, the court is not allowed to let you recover attorney's fees. You will have to pay them, even if you win.
Sound like the deck is completely stacked against you in a self-funded plan? It is.

I have heard of two cases where the employer denied because, "You have a higher salary than most of our managers. If we pay for your cancer surgery, the other employees would be jealous."

They can say whatever they want, they can deny for any reason they choose. You have no protection, you have no recourse, there is nothing you can do about it. It is a self-funded plan.

Elizabeth's employer spits in my eye :raspberry:

Last week, I fought a fierce appeal for Elizabeth from Boston. She needed the same lifesaving surgery that I received four years ago. Her surgery is scheduled for October 20.

It is a self-funded plan: Philips Healthcare is the employeer, with Empire Blue Cross Blue Shield as the "insurer."

I deployed my usual strategies, and prepared and delivered my usual masterpiece of persuasive expository prose. In response to my appeal document, the president/CEO of Empire BC/BS contacted Elizabeth personally, and hooked her up with a decision-maker who could move her case along.

By Thursday afternoon, Empire BC/BS had approved the treatment. They promised to have a single-case contract ready for signature and on Dr. Sugarbaker's desk by 4:00 p.m.

At 2:00 p.m. on Thursday, Philips intervened. They said, in effect, "We don't care if the insurer approved. We aren't paying."

Yes, they can do that. And so can your employer. Pay heed to the fine print in your plan documents:
Philips, as the Plan Administrator, shall have the exclusive right, power, and authority, in its sole and absolute discretion, to administer, apply and interpret the plan and any other plan documents and to decide all matters arising in connection with the operation or administration of the plan.
Sound like your employer has divine power over your life and death? They do. Run, run like the wind from self-funded plans.

********
Happy and peaceful Insurance Warrior-ing,

Laurie Todd

http://www.theinsurancewarrior.com/ (http://www.theinsurancewarrior.com/)

Know anyone who is fighting an appeal? Steer them to my new CD, The Sample Appeal.

www.theinsurancewarrior.com/thebookandthecd.html (http://www.theinsurancewarrior.com/thebookandthecd.html)

2cool4U

10-18-2009, 11:13 PM

Unfortunate situation. However, how does an employee "run like the wind from self-funded plans?" It's not like an employee typically has several options of health care plans to choose from. And small businesses with high employee health care costs may not be able to choose other plans to offer to their employees. In the latter, the small business owner is saddled with a high deductible for each employee, and the owner has to pay if there is an illness. That deductible can run $10-20K per employee per year. The costs can be staggering if only a few employees (or covered family members) develop chronic illnesses. Those same costs then result in the employer being unable to secure a different health insurance plan for the business.

Once again, unfortunate, but does the author suggest that people turn down jobs in this economy if the potential employer has a self-funded insurance plan? Or is there a suggested course of action here that would lead to action on the part of our lawmakers that I missed?

-tc-

Harrison

12-28-2009, 09:54 PM

Well, copyright infringement (http://www.adrsupport.org/forums/showthread.php?p=85059#post85059) seems to be a common theme tonight! Any way, Laurie's column is below...thanks Laurie!
___________________________________________

The Insurance Intelligencer
12/28/09
The Biologist and the Plagiarist

Steve is a fish biologist from Eastern Washington. This month, we fought the appeal for Steve's wife Maria -- through two levels of internal appeal, two independent reviews, and one in-person hearing. Because of Steve's scientific curiosity, lies were revealed, illusions dispelled, and a plagiarist unmasked.

The good news? We won.

When I heard that there was a couple in Eastern Washington who needed to get to Dr. Sugarbaker -- and had Premera Blue Cross Blue Shield -- I thought, "Piece of cake." In 2007, I had already won that battle for Norma. I wrote a big mean letter to Premera, and Norma's husband Kim exploited his business connections, and called the medical director. Within twenty-four hours, we had approval. What could be easier?

Never underestimate your opponent.

The written appeal

Am I getting too good at writing appeals? Up until a few months ago, insurers received my appeal documents, and either approved or denied the treatments. All of a sudden, insurers are finding ways NOT to decide.

On receiving my appeal for Maria, Premera immediately sent it to an "independent review organization." This was not the next step according to their appeals process. I believe that the appeal was such a hot potato -- so embarassing to Premera -- that they did not want to uphold their denial, and they did not want to be responsible for reversing their denial. So, they sent it out to independent review.

The independent review

"Independent review" sounds like a good thing. It sounds like due process, taken out of the hands of the insurance company, yes? An "independent review organization" sounds very official -- like an institution. Surely an independent review org has many many experts on staff? They are qualified, regulated, diligent and impartial? How I wish that they were.

The independent review came into being in response to patients who were denied treatments by their insurance companies. These patients were also voters, and they put pressure on their elected officials, saying, "The businesses that will have to pay for our treatments gets to decide whether they are 'medically necessary' or not. This is wrong, it is the world's worst conflict of interest."

Independent review orgs sprung up like mushrooms, and state insurance commissioners and insurance companies added a new layer to their appeals process -- independent review. I assume that this development quieted the clamor to remove medical decisions from the hands of insurance companies.

When we are ill, and are denied the one treatment that could save us -- we want desperately to believe that there is some powerful entity that will step in and help us. This is a dangerous -- sometimes fatal -- belief.

More and more, insurers and employers (in the case of self-funded plans) hand medical necessity decisions off to independent review orgs. Who are these organizations, who hold your life in their hands?

Independent review organizations are not licensed. Some states require them to have "clinical peer" reviewers, some don't. They are not accountable for their decisions. An independent review org could uphold 100% of the denials sent to them, and nobody would ever know. Often, they are the end of the line for you; there is no more due process after the independent review.

Guess what? In some states, the insurance company doesn't have to abide by the decision of the independent reviewer. In these states, why do they bother to do them? Talk about your illusion of due process.

Like insurance companies, independent review orgs understand the power of words. They dream up power names like "Maximus." ("We will crush you like a bug!") Or quasi-medical names like "Medical Review Institute" (MRI).

The first time that one of my cases got sent to independent review, my helpee was thrilled, "They are independent ... that's got to be good, right?" "Hold your horses," I replied, "Let me find out who these people are."

The requested treatment was cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for appendix cancer with peritoneal spread. The independent review org was a chiropractor in Texas with a post office box.

The plagiarist

Premera was so razzle-dazzled by our appeal that they prematurely sent it out independent review. The reviewer -- a breast cancer doctor -- upheld the denial.

Steve and I found the denial letter very strange. It didn't mention any of the insurer's stated reasons for denial, and it didn't address any of the points that we had approved in our written appeal.

The last page of the reviewer's letter mentioned an obscure article which Steve had never seen before. Because of his scientific curiosity, he googled the article.

This article appeared in only one place -- a blog called "Cancer Treatments." This blog lists hundreds of different cancer treatments, and gives a generic paragraph or to to introduce them to laymen.

The verbiage sounded familiar to Steve. Pages two and three of the reviewer's three-page decision were plagiarized directly, word-for-word, from the blog post about cytoreductive surgery. The entire post was cut and pasted into the reviewer's letter.

Some expert. Some review.

The hearing

After the sham independent review -- and five days before Maria's surgery date -- Premera ordered my helpees to drive over the snowy Cascade mountain range, to present our case once again, at Premera headquarters, at an in-person hearing. I wrote a speech for Steve, and a speech for me.

Our presentations must have been powerful. Once again, Premera denied, and handed off the case to another independent review organization.

This time, I insisted that the reviewer have relevant clinical experience, and that the reviewer receive and consider every page of information that we had prepared -- including both of our speeches.

Within a few days, the denial was reversed, the treatment was approved, and Steve and Maria were on their way across the country for her lifesaving surgery.

Disclaimer: I am not saying that no insurance denial is ever overturned on independent review. I am simply saying not to count on it. Know that an independent reviewer is not necessarily qualified to render an opinion on your treatment, and may not even bother to learn about it. They may, they may not. In other words, do all you can to win your appeal -- before it ever gets to the Bermuda Triangle that is independent review.

******

Maria had her surgery on December 16. Dr. Sugarbaker was able to remove all of the cancer, and to perform the heated intraperitoneal chemotherapy. A good outcome, and a promising future for Maria. Now she builds her strength, walking to the patient lounge, and watching the snow fall peacefully in Washington, D.C.

A little bird has told me that another patient from my area needs to get to Dr. Sugarbaker. Guess who is her insurer? Premera Blue Cross Blue Shield. Here we go again.

Looking forward to my Class of 2010,

Laurie Todd
http://www.theinsurancewarrior.com/ (http://www.theinsurancewarrior.com/)

Harrison

01-25-2010, 08:26 PM

Max's Head

Remember six-month-old Nicholas, who had his skull fixed by Dr. Fearon? It wasn't long before Nicholas from Michigan led to Max from California.

While we were fighting Max's appeal last week, his mom Cassie was wrangling a two-and-a-half year old, and a six-month-old who doesn't sleep. They live in Southern California. Torrential rains were falling, and the power was going on and off.

Our opponent was Anthem Blue Cross of California -- the biggest, baddest, most loaded-for-bear insurance company in the entire country. The last time I faced off with Anthem, they won.

Will the house wash away? Will Laurie be defeated by the Goliath of health insurance? Will Cassie tear off all of her clothes, and run screaming into the street?

What is this surgery, anyhow?

When babies are born, the many sutures that connect the parts of the skull are soft and pliable. They fuse gradually, to allow the brain to grow in just the right directions. In babies with craniosynostosis, one or more of the sutures fuses prematurely. The head immediately takes on an unusual shape.

In order to fix this condition, the skull is taken apart and expertly refashioned, with just the right amount of space left for the brain to grow. The problem is that the surgeon who gets the best outcomes with this surgery is in Dallas, Texas, and he is not contracted with Blue Cross Blue Shield.

With insurance companies, there is a tremendous push to keep us in-network and local -- regardless of the qualifications or expertise of the local in-network surgeons.

Anthem sent Cassie to some fine, fancy, distinguished neurosurgeons in Los Angeles. She was very comfortable with them. The only reason why she decided to fight to get to Dr. Fearon was because the local surgeons all told her that catastrophic bleeding is a common complication of this surgery, and Max would definitely need a transfusion. Dr. Fearon has made innovations that drastically reduce the rate of transfusion.

It was the transfusion that bothered her. Little did she know that it was the type of surgery that the local surgeons were offering that should have given her pause.

The Pi-procedure

I had Cassie write Max's medical story. Then, I questioned her, "What did the surgeons tell you about the surgery that they would do for Max? How did they describe it? What did they say?" I need to know what the in-network doctors are offering, so that I can contrast it with the elegant posterior cranial vault remodeling performed by Dr. Fearon.

Try as I might, I could not figure out what they were doing. It was all very murky and vague. What was this surgery being performed in Los Angeles?

I was able to find an article by a nurse at Children's Hospital in Los Angeles, describing the surgery that they do there. I still couldn't figure it out. How was I ever going to make this clear to Anthem?

Finally, I sent the article to Dr. Fearon, who replied, "This article describes a type of strip craniectomy called the Pi-procedure."

Ah, the Pi-procedure! It is not the same as what Dr. Fearon does. The skull remodeling is so simple that a neurosurgeon often performs it without the assistance of a cranio-facial surgeon. The doctor cuts out the fused suture, and discards that part of the skull. He then cuts out two strips next to it, and joins the whole business together with plates and screws.

I crafted the thirty-four-page appeal, complete with diagrams, and sent it to Cassie. She called me, "I had no idea."

"They didn't explain it to you, did they?" I replied.

We have a dream

When people lose an appeal, I counsel them to do things differently the next time. Last time, when I lost to Anthem, I came out with all guns blazing. This time, I held back a little bit. I decided that, with Anthem being so big and powerful -- if I came out swinging, they would hit me upside the head with a 2 x 4.

So, I softened my approach. There were no titles like, "Anthem BC of CA violates state law such-and-such." I stated all of the powerful facts. However, I also gave Anthem a degree or two of slack, to leave a little room for compassion to rush in and fill the vacuum.

I deployed the appeal copies by fax and email on Sunday night, as usual. I forgot that Monday was Martin Luther King day.

The compassionate Buddhas must have been watching, because the holiday turned to our advantage. One of the many executives to whom I addressed the appeal was working on Monday. High-level executives at insurance companies are instructed never to read appeals, of course. I make them as irresistable as possible, to overcome that obstacle.

Our executive sent me a very respectful reply on Monday evening, and told me that he would handle it. (These higher-ups often think that I am the insured person, because the email or fax comes from me.) I believed him.

The next day, Cassie heard from Anthem -- "We're working on it." On Thursday, the surgery with Dr. Fearon was approved.

Cassie did not run screaming into the street, the house didn't wash away, and Laurie had her sweet victory.

Best of all, little Max will have his surgery.

Happy and peaceful Insurance Warrior-ing,
Laurie Todd
www.theinsurancewarrior.com (http://www.theinsurancewarrior.com/)

Harrison

03-04-2010, 06:25 PM

The Emperor Has No Clothes

A woman in Minnesota sent me a copy of her appeal. She had followed all of the suggestions in my CD. She did the research, performed her due diligence, proved her points.

When I read this appeal, I knew that it wouldn't fly. She sounded too much like an eager student, hoping for an "A." It was earnest, not intimidating.

An illusion of due process

In order to face off against an insurer, and win the battle on their home ground -- we need to bear in mind that the appeals process is not meant to lead to an approval.

Appeal levels, peer reviews, hearings, committees, independent reviews -- none are meant to lead to an approval. If we believe that we will get unbiased consideration at any of these levels, we miss the poiint, we charge up the wrong hill, we are barking up the wrong tree.

Disclaimer: I am not saying that no medical director ever considered a treatment in good faith, based on whether or not it was safe and effective. I've just never seen it happen.

How can I tell that this system of appeals and grievances is a stacked deck? Let me count the ways ...

The telephone game

You are allowed access only to people with no decision-making power -- customer service reps and case managers. This phone interation is not meant to bring you any closer to an approval.

What is the job of a customer service rep? To tell you to wait for a letter. What is the job of a case manager? To tell you to wait for a letter.

First and second level reviews

A treatment is "medically necessary," if the medical director of the insurance company says it is. It is "experimental," if the medical director of the insurance company says it is.

In all of my fifty-seven cases -- the medical director knew nothing about the treatment under review, and he was not qualified to render an opinion on the treatment. The majority of these medical directors are "family practice physicians." It must be slow times in the "family practice" business, since so many of them have resorted to working for insurance companies.

My favorite unqualified medical director had denied reconstructive skull surgery for one of my infant helpees. He was a psychiatrist. We joked, "Hey, I guess they figured head/skull, same geographical location ..." At a certain point, I said to her, "The next time you call that medical director, tell him that these denials are driving us CRAZY, and we need a session!" He knew nothing about skull surgery, nor did he care to learn about it.

I have never seen an insurance company reverse a decision from first- to second-level review. Unless, of course, they received a powerful appeal from the patient in the interim. One medical director will not rule differently than another; they both work for the same insurance company.

Medical policy statements

Med policies are a body of hundreds of official-looking documents. Every insurer has them. They give the scientific reasons why the insurer isn't going to pay for your treatment. No matter what your coverage is, they aren't going to pay for it.

Medical policies were instituted in the 1990s in response to a hue and cry from outraged insured people. They had figured out that insurers could pretty much call any treatment "experimental" or "not medically necessary" -- with little or no justification.

Med policies are supposed to hold insurers to some kind of scientific standard. Guess who writes them? Insurance companies.

If you don't believe that medical policy statements are sham documents -- consider the Tale of the Two Medical Policies.

I decided to find and print all of the medical policy statements that I could find for hyperthermic intraperitoneal chemotherapy (HIPEC) -- the treatment that I had in 2005, and for which I have written many appeals.

The med policy from Blue Cross Blue Shield of Massachusetts started looking familiar. It declared HIPEC to be "medically necessary," and cited twenty-nine medical articles and other sources. I pulled out the Premera Blue Cross medical policy, which deems this treatment to be "experimental." Both med policies used the same twenty-nine articles to prove that HIPEC was both experimental, and not experimental.

These documents are not designed to hold insurers to any standard. They are meant to look official, with the expectation that nobody but me will ever challenge them.

Peer reviews

The peer review is where the same medical director who denied the treatment the first time calls your doctor, and tells them why they aren't going to pay for it. This medical director is a family practice physician. He is not a surgeon, a cancer expert, or any other type of "peer." He is not a peer, and it is not a review.

Independent reviews

People get pretty excited, when they lose a few appeal levels and their case goes to independent review. They say, "It's independent, that's got to be good, right?"

Like med policies, independent reviews came into being because people got fed up with insurers denying whatever they wanted to deny, with no checks and balances. Only problem? There are no checks and balances on independent review orgs.

Independent review organizations are not licensed or regulated. They are not required to employ "medical experts." In many states, they are not held to any standard at all. I delved into an independent review org that was about to rule on one of my cases -- it consisted of a chiropractor in Texas with a post office box.

Independent review orgs are not accessible, and they are not accountable. They could uphold every denial that came their way, and nobody would ever be the wiser.

Word to the wise: If you want to make the most of this illusion of due process, at least put a powerful appeal in front of these review org people. Even if they know nothing, and aren't required to do anything -- that chiropractor in Texas might be impressed enough to reverse your denial.

In order to win our appeals, we need to know our opponent, and stay focused on the big picture. The only due process that we can expect from our insurance companies is the due process that we create ourselves.

Listen to my new audio spot:
http://www.carcinoid.org/insurance/index.shtml

*******

My two books are now available as E-books!
http://www.theinsurancewarrior.com/ebooks.html

More affordable, instant download!

Harrison

06-28-2010, 02:35 PM

The Insurance Intelligencer
6/28/10

The New Healthcare Law: Protection, or Pretense?

The media hoopla over the health care bill is over; the bill has been passed. As of 3/23/10, the Patient Protection and Affordable Care Act of 2010 (PPACA) is the law of the land. May we assume that the inequities, cruelties, and brutal realities of private health insurance are now tempered, improved, resolved?

Legions of healthcare lawyers are currently poring over the PPACA. I am just one cancer survivor -- one who has won fifty-nine major insurance appeals for others by understanding the real reasons for insurance denials, and what it is that motivates insurers to reverse those denials.

I would like to share a few provisions of the law that stood out for me, given my experience with how insurance company policies, provisions, and decisions play out in the real lives of patients, and the dedicated medical providers who treat us.

Grandfathering

Grandfathering = the mother of all loopholes, right off the top. Which insurance plans will be exempted from the new law? All insurance plans in existence on the date the law was passed. All of them.

There are a few provisions of the new law that do apply to existing group plans: health insurance for employees working thirty hours or more, dependent coverage for children up to age twenty-six, various restrictions on denials for pre-existing conditions.

However, the bottom line is that all existing insurance plans are exempt from most of the provisions of the new law. They can continue to operate as they always have, they can enroll new members. Business as usual.

Disclosure

There are all manner of complicated disclosure requirements for insurers offering new plans. Just one problem with this -- insurers have had fifty years to perfect the art of "concealing, while appearing to disclose."

Good luck getting insurance companies to disclose.

Example #1: Let's say that insurers are required to disclose their number of treatment denials. My lifesaving surgery was denied in 2005; I have the denial letter in my files. However, as far as my insurer is concerned, there was no denial. In their records, the entire episode is classified as a "goodwill payment."

Example #2: Under the new law, insurers offering new policies will need to disclose their "claims payment policies and practices."

I could write a dissertation on how health insurers reduce reimbursement, after the medical treatment has been performed. Bundling codes, changing codes, deleting codes -- the variations are endless. Some insurers even go retroactive -- digging into past cases, looking for ways to take away even more payment.

However, the biggest, most secret, most baffling practice to patients is the infamous "reasonable and customary." All of the disclosure requirements in the world will not unmask nor demystify this massive illusion of coverage.

Let's say that the patient has a PPO. Their benefits booklet states that the insurer will pay "80% for out-of-network treatment." The truth, but not the whole truth. Every patient who has ever contacted me -- regardless of their level of education or sophistication -- believes that the insurer will be 80% of billed charges. Patients embark on astronomically expensive surgeries and hospitalizations, believing that 80% of their bills will be paid.

Far from it. The insurer will pay 80% of whatever the insurer deems to be "reasonable and customary." If you call your insurer, and ask, "What does reasonable and customary mean?" -- they will reply, "We do extensive research and surveys, all over the country, to see what medical providers are charging."

There is no research, and there are no surveys. The numbers upon which insurers base their reimbursement are secret, mysterious, and constantly changing.

Guess where insurers get these figures? Ingenix. Guess who owns Ingenix? United Healthcare.

In 2008, New York attorney general Andrew Cuomo took sixteen major insurers to task for this misleading-to-fraudulent practice. Ingenix was fined $300 million, plus $50 million to set up a non-profit database to generate the numbers on which reimbursement will be based. How fair and impartial this new set-up will be remains to be seen, as the first of the sixteen insurers just settled with Cuomo this January.

When we require insurers to disclose their reimbursement practices, they will simply say, "Our reimbursement is based on reasonable and customary charges."

Very few consumers will ever ask, "What do you mean by that?"

External review

64% of the employees in this country are insured by self-funded plans. People, this means that your employer -- who knows nothing about the practice of medicine -- has absolute power over your life and death.

The only check on this divine right is the federal district courts. Good luck with that, when surgery is scheduled for next week.

The new healthcare law requires that self-funded plans submit their denials to "external review." What is external review, and is it up to this herculean task?

Independent/external review processes came into being in the 1980s, because many people got fed up with insurers and employers having sole decision-making power over medical treatments. People thought, "It's independent, it's got to be better, right?"

In early 2009, a woman called me from Colorado. She had exhausted all of her internal appeals with the insurer; she was on her way to independent review. I said, "Hold your horses. Who are these people?" The case under review involved a massively complex abdominal surgery for cancer, with heated intraperitoneal chemotherapy.

It took me twenty minutes to discover that the "independent review organization" was a chiropractor with a post office box in Texas. It was not an organization, and it was not qualified to perform a review.

This external/independent review process is anonymous, unregulated, unsupervised, and accountable to nobody. They could uphold every denial that came their way, and nobody would ever know.

Is this not a fragile branch upon which to balance the lives of 64% of the employees in the United States?

******

Just a few thoughts about the new healthcare law. I will constantly be looking for ways in which I can use it to help you, when your treatment is denied.

Happy and peaceful Insurance Warrior-ing,

Laurie Todd
health insurance help (http://www.theinsurancewarrior.com/)

Harrison

07-29-2010, 08:00 PM

Not enough scientific proof?

How many of you have had a treatment denied, written an extensive appeal, then lost -- only to be told, "There is not enough long-term scientific proof"?

Insurers love this reason for denial. They love it so much, that they often say it, even when it is not true. It sounds so factual, so fair, so indisputable.

I have never lost an appeal for "not enough scientific proof." And I do not want any of you to ever lose an appeal for this reason.

There are many ways to overcome this objection. Let's talk about one of them ...

Evidence-based medicine?

When your insurance company is being ridiculous, you need first to recognize it, and then point it out in your appeal.

In 2009, I took on the case of Amy from Colorado. She had an advanced case of ovarian cancer, which had spread throughout the abdomen. For several years, her local doctors had been treating her with repeated "debulkings," and systemic chemotherapy.

"Debulking" means "taking out the bulky tumors, and leaving the rest." What if you had breast cancer? Would it make sense to you to if the surgeon said, "We will take out the big tumors, and leave the rest"? Not the most effective approach.

Only problem is, it is much more difficult in every way to clean all visible tumors out of the abdomen than it is to remove all visible tumors out of the breast. There are surgeons who know how to do it. However, the are not usually local, and they are not often in-network.

Finally, after years of recurrences and more treatments, Amy happened to hear about the one definitive treatment for cancers which have spread throughout the abdomen -- cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). She wanted to get to the surgeon with the best documented long-term outcomes with this complex surgery and treatment.

All of Amy's available appeals had been denied. It was now my job to get the denials reversed, and the treatment approved.

Turnabout is fair play

When I write an appeal, I do my best to anticipate whatever arguments the insurance company is going to come up with. After winning sixty lifesaving appeals, this is fairly easy to do.

Insurance companies have paid for cytoreductive surgery and HIPEC hundreds if not thousands of times. Many of the insurers' medical policy statements endorse this treatment -- for appendix cancer. Not for ovarian cancer.

The standard treatment for ovarian cancer is repeated debulkings and systemic chemotherapy. If the patient is lucky, they may get IP chemotherapy along with the debulkings. This is what they do, doctors and insurance companies are very comfortable and attached to this treatment regimen -- regardless of how effective or ineffective it may be.

Wake-up moment: Just because a treatment is routinely offered in-network, doesn't mean that it is effective, the most effective, or scientifically proven.

I stayed up half the night, learning about ovarian cancer, the treatment of it, the scientific articles about it. I found the followin gold nugget, and I presented it in the appeal:

I quote from Peter Schwartz, MD, John Slade Ely Professor of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine:

"The standard management for previously untreated advanced-stage epithelial ovarian cancer is optimum surgical debulking followed by aggressive cytotoxic chemotherapy. This approach is based on a retrospective review of a single-institution experience published more than thirty years ago and has yet to be confirmed in a prospective randomized trial."
(Schwartz, PE. Cytoreductive surgery in the management of ovarian cancer. Oncology 2008; Vol 22:9.)

When I found this, I almost fell off my chair. The standard treatments that are offered all over the United States for ovarian cancer are based on one scientific article -- a retrospective study of patients at one institution, published more than thirty years ago. No randomized trial, no long-term outcomes.

The insurer is not offering "evidence-based medicine." It is rather embarrassing, when I point this out to them in an appeal.

The same is often true, regardless of the treatment. Need artificial disc replacement? They tell you there is "no scientific proof of long-term outcomes"? How much scientific proof do they have for the treatment that they do offer -- spinal fusion? Zero.

******

Insurers need to be held to the same standards to which they hold us. You and I -- the patients who are denied -- are the only ones who are going to do it.

When we request a treatment that is either out-of-network, or more than fifty miles from our house, the insurer demands a level of proof that they would be hard-pressed to provide for the treatments that they ARE offering.

The emperor has no clothes.

When your insurer is being ridiculous, you need to recognize this, and point it out to them in your appeal.

Happy and peaceful Insurance Warrior-ing,

Laurie Todd

Harrison

10-03-2010, 07:33 PM

The Insurance Intelligencer
10/4/10

October 4, 2010 is a very important day in the history of Insurance Warrior-ing. It is the fifth anniversary of the fourteen-hour surgery that saved my life.

In order to get this lifesaving treatment, I had to learn that my local doctors were not telling the truth. They lied to me, and they were dead set against my having this treatment. I had to confront the full bureaucratic might of my insurance company, which had no intention of paying for it. All while fighting a late-stage abdominal cancer. All because the one treatment that would save my life was "out-of-network." If this month's newsletter sounds like a cry from the heart .... it is. It's all about the networks...

A little history

When treatments are denied, people go first to the insurance company for help, then to their doctor. This demonstrates that insurance companies have been very successful in hiding how this system really works.

Going to the insurance company for help when treatments are denied is like going to the fox for help, when chickens go missing from the henhouse. It is the fox's job to take a chicken for his dinner, and it is the insurer's job not to pay.

There is nothing bad or evil about this, it is just the way of life. An insurance company is a business, and a business is tasked with reducing operating expenses. To your insurer, any money that they spend on medical treatments is considered the "medical loss ratio." It is critical to your insurer to reduce this "loss" as much as possible, every month. If they don't their institutional investors will rush to another insurance company -- one that pays out less for medical treatments.

Doctors and networks

Going to your doctor for help, when treatments are denied? The entire system of "managed care" was designed to take away the power of doctors, so as to limit their ability to order expensive tests and treatments. Before 1970 or so, insurance companies and doctors were two separate entities. If the insurance company denied a treatment, your doctor had the power to go to bat for you.

Health insurers came up with an extraordinarily effective way to control doctors, with a diabolically friendly name: managed care. We manage. We care.

There is very little difference between HMOs and PPOs. PPOs are simply HMOs, hiding behind an illusory "out-of-network" benefit. In the PPO, out-of-network treatments have to be pre-authorized, and are often denied. Further -- and herein lies the biggest deception -- when PPOs do pay for out-of-network treatment, they pay based on a percentage of a secret number which they themselves generate -- the "reasonable and customary" shell game.

The danger of networks and medical care goes far beyond denial of out-of-network treatments. I had a late-stage, metastasized abdominal cancer. The in-network doctors had no curative treatment for it. Their plan was to do more surgeries as my tumors repeatedly filled my abdomen, then to watch me die. There was no scientific proof that these treatments would extend my life, or improve its quality in any way. There was a tried-and-proven treatment for my disease which had been practiced for over thirty years -- cytoreductive surgery and HIPEC -- with hundreds if not thousands of peer-reviewed medical journal articles, consensus statements, and other proof of its safety and effectiveness.

My local in-network doctors were not the slightest bit interested in this treatment. They did all they could to discourage me from getting it. Why? Because it is out-of-network; therefore it does not exist. When physicians have lived with networks for two generations, we have a world where ignoring the one treatment that can save your life -- or your child's life -- is encouraged, rewarded, and exceedingly OK.

Networks also nurture the concept that it is the job of a healthcare delivery system to treat the greatest number of people, with the most common illnesses, and offer the lowest common denominator of treatments.

I was watching the Today show last week. Matt Lauer was interviewing a guest about the latest in health insurance. The guest mentioned that, if you go out of network, the costs can be astronomical. Matt smiles and says, "So, just don't go out of network, right?" Smile and say that again, Matt, when your child has an aggressive, fast-moving brain tumor, and the only surgeon who can remove it is out-of-network.

A PPO is really an HMO

The dark heart of all healthcare plans -- PPO or HMO -- is networks. Doctors can be squeezed, harrassed, disempowered, and underpaid in this "network" system. Insurers are empowered to rob, abuse, injure, mislead, and often kill those who seek effective treatment within this system.

Networks are a vast body of contracts. Insurers have had fifty years to perfect these contracts so as to retain all decision-making power to themselves. Contracts between insurers and doctors, contracts between insurers and patients. Many of these contracts between you and your insurer state: "A treatment is medically necessary if the medical director of Acme Insurance says that it is medically necessary." Because we say so. We who are going to have to pay for it.

Does this not sound like the world's worst conflict of interest to you? Why aren't millions of insured people marching in the streets? Because insurance companies have had fifty years to perfect the managed care system. They have also had fifty years to perfect the publicity machine that makes them look like wise, benevolent, benign social service agencies who are there to help us.

Want to reform the healthcare system? Abolish. All. Networks.

To ignore a treatment because it is out-of-network is wrong.
To deny a lifesaving treatment because it is out-of-network is wrong.
The worst, in my estimation? To lie to a patient to discourage them from going out of network.
In a healthcare system based on networks, it happens every day.

******

And so, we end where we began. On October 4, 2005, I arrived at Washington Hospital Center in Washington, D.C. at the crack of dawn. I underwent a big whomping surgery, a whole lot of intraperitoneal chemotherapy, and forty days of abject misery in the hospital. I won't sugarcoat it.

I have not needed any medical treatment since I returned from Washington, D.C. in December 2005. I have had no recurrence, I remain free of disease. I eat Mexican food. I'm fine.

I just finished writing appeals #64 and #65. I have written and published two books during the past five years, and sold a few thousand copies of them. I have travelled all over the United States, speaking before all manner of groups. I speak to them about how, when life suddenly spins out of control, it is possible to win great victories.

A new career found me, right in the place where I was fighting, learning and living. I became the Insurance Warrior.

The fact that all of this grew from those perilous days amazes me. All that I did was show up, take my lumps, do the important things right, and cultivate an open heart. Had I believed my local doctors -- and the insurance company who denied me -- I would be long gone, and none of this would have happened.

As far as I'm concerned ... it happened just as it needed to, and it is all good.

Happy and peaceful Insurance Warrior-ing,

Laurie Todd
health insurance help (http://www.theinsurancewarrior.com)

Tatonka_usn

10-03-2010, 11:35 PM

All I can say is WOW!! Can't recall anything echo'ing my inner thoughts in quite some time. Very profound, and VERY accurate. :mad:

Alan

Harrison

12-03-2010, 11:47 AM

Employers and insurers: Dangerous Liaison?

I recently happened across an article entitled, "Tax breaks for employer health plans a target." The article continues:

"Job-based health care benefits could wind up on the chopping block if President Barack Obama and congressional Republicans get serious about cutting the deficit."

Really? I may just be in favor of this.

An accident of history

Sometimes, when things have been a certain way for two or three generations, we come to believe that they have always been that way, they have to be that way, they can be no other way.

Once upon a time, slavery was considered to be the way of life and business in the United States. It had been that way for generations, it was impossible to imagine any other way. We can look back on slavery now, and say, "It was a terrible idea. The world's worst idea."

It is a pure accident of history that, in the United States, health insurance came to be hooked up with employment. In my estimation, it is a terrible idea, and one that doesn't have to be.

Lose your job, lose your insurance

Can anyone think of reasons why having your employer provide your health insurance might be a bad idea?

I have been fighting lifesaving appeals for five years. I just won appeal #66. If you can't think of any reasons why having your employer in charge of your health insurance is a bad thing ... I can. I have seen this unholy alliance wreak havoc on the lives of people who are ill, and on their families.

When your employer provides your health insurance ...
If you lose your job, you lose your health insurance.

You have to work when you are sick, or you will lose your job, and you will lose your health insurance.
Is this not insane? It just doesn't add up. Who is it that decided that people should lose their health coverage if they are too sick to work?

How exactly are people supposed to continue working ... after they have a fourteen-hour cancer surgery, or they have a bone-marrow transplant, or they are paralyzed on one side from a stroke. Health insurance should not be dependent on one's ability to work, because being sick (i.e., needing one's health insurance) often makes one unable to work.

When your employer IS your insurer

But it gets worse. Insurers have quietly been promoting the living daylights out of "self-funded" plans. If you haven't gotten the message from me yet ... in a self-funded plan, you give up most of your rights, and your employer is granted divine rights over your life and death.

These self-funded plans are such sweet deals for insurers ... without you knowing it, they have infiltrated employer-based group insurance all over the country. Two-thirds of the employed people in the United States now have self-funded plans. In my experience, zero percent of these employees know that they have a self-funded plan, or what a self-funded plan means.

Does it sound like perhaps insurers may not want you to understand what you are getting into, when you choose a self-funded plan?

When you have a self-funded plan ...

The money to pay for your medical treatments does not come from the insurance company. It comes directly out of your employer's bank account. The insurer has hoodwinked the employer into assuming financial risk for your medical treatments, and doing the dirty work of denying those treatments.

Your employer has sole decision-making power on all of your benefits. In other words, your employer gets to decide whether or not your child gets a heart transplant. Heart transplants can cost in excess of $1 million.

In a self-funded set-up, the insurer magically changes itself from an insurer to a "third-party administrator." Therefore, your state's insurance regulations no longer apply to them.

Your employer is not an insurer, either. The only law that governs self-funded plans is federal law (ERISA). Good luck calling the Department of Labor about your denial of treatment. You could appeal it, but you would need to hire a lawyer to navigate the ERISA system. Plus, it could take a year to win it. Good luck with that.

How do insurance companies get employers and employees to sign up for this bad deal? It's easy ... the costs of a self-funded plan are less for the employer, and the monthly premiums are less for the employees. For that, you are essentially selling your life to the company store. Penny wise, and pound foolish.

Of course, many of us have to submit to a self-funded plan, because it is all that our employer offers. Wait a minute ... what about all of that choice and competition and free market economy that was supposed to bring down the cost of health insurance? With employer-based health insurance, we often have no choice.

How does this self-funded thing play out in real life? Employees who are desperately ill with cancer find themselves fighting their insurers AND their employers when treatments are denied ... all the while fearing that they may lose their jobs, and their health insurance.

Guess what happens when an employee puts too much of a drain on a self-funded system? A longtime friend of mine worked for a company for twenty-three years. She had two bouts with cancer while working there, plus other chronic health problems. The company laid off forty-seven people at once, including my friend; forty-two of them had had expensive cancer treatments while working there. Coincidence?

In what universe is this a good idea? It is not only cruel, but ignorant. Who decided that Boeing or Microsoft or Acme Widget Company is qualified to decide whether or not you need brain surgery ... or to get rid of you if you need too much brain surgery?

There has to be a better way

One of the goals of the Affordable Healthcare Act (Is your healthcare any more affordable since it passed, by the way?) was to reduce the number of uninsured people in the United States.

Since the Affordable Healthcare Act passed, the number of uninsured people has risen by at least 2.8 million. Why? Because they have lost their jobs. In March of 2009 alone, 320,000 people lost their jobs, and became uninsured. COBRA lasts but a short time, and they will soon have no insurance. What can the Affordable Healthcare Act do about that, as long as health insurance is tied to employment?

What about those "risk pools" that many states have, where the "uninsurables" among us (that would be most of us) can get insurance? Last time I checked, the monthly premium in my state for a 50-year-old non-smoker was $986 per month. Does that fall under your definition of "affordable" ... particularly if you are applying for it because you lost your job?

And so, I find myself in the strange position of agreeing with the GOP on this one. By all means, let's cut the several hundred billion dollars in tax cuts that are given to employers for making medical decisions, side-stepping state insurance regulations, and taking away our health coverage just when we need it the most.

Employers have no business offering health insurance, administering health insurance, paying for medical treatments, or deciding about medical treatments. An employer should have ultimate power over our jobs -- not over our lives.

Someday, we will look back on this system of employer-administered health insurance, and say, "How could anyone ever have thought that was a good idea?"

Holiday cheer and peaceful Insurance Warrior-ing,

Laurie Todd
health insurance help (http://www.theinsurancewarrior.com/)

Harrison

01-25-2011, 10:48 PM

I've been sharing Laurie's newsletters for some time now (years), and some of us who take the time to read her analysis have been rewarded with her insights. We've also been troubled with her findings. Sorry to be gloomy, but tell me I am wrong...then explain why.
__________________________________________________ ___

Insurance Warrior News - 1/24/11
Expensive prescription drugs: Are you covered?

Over the past thirty years, total spending for healthcare in the United States has more than doubled as a percentage of the gross national product (GNP). As of 2010, this figure stood at 17.3% of GNP. The Congressional Budget Office estimates that this figure will grow to 31% of GNP by 2035, and 46% of GNP by 2080. Imagine 46% of the total market value of all of the goods and services in the United States being spent on healthcare.

The cancer drug Erbitux costs $4,700 per month in the England, $12,000 per month in the U.S. In a report published in 2009, the Department of Health and Human Services projected that prescription drug spending would increase from $234.1 billion in 2008 to $457.8 billion in 2019 -- almost doubling over the 11-year period.

I do not approve of the subterfuges and strategies that insurance companies use to shift costs to patients. However ... no private insurance company, no government, no entity of any kind has enough money to pay these wild, astronomical, out-of-control medical expenses. Rather than face the terrible problem of runaway hospital costs, drug and medical device prices, insurers have come up with a million ways not to pay for them. Or, when they pay, to pay as little and as late as possible.

Until we get to the bottom of why medical care costs twice as much in the United States as it does in Europe, all efforts to make insurers really cover us will only result in the insurers finding new and more clever ways not to pay.

Nobody can afford these charges -- least of all the patients.

A case in point: Expensive prescription drugs

Over the past couple of months, three cases about expensive prescription drugs have come my way. I did not end up writing appeals for them, but I did enough research to get a glimpse of the "cost containment approachs" being used by both Medicare and private insurers with regard to prescription drugs.

Which drugs are insurers most likely to not pay for? Expensive drugs.
Which drugs are most likely to be expensive? Drugs used to treat cancer.
How do insurers get out of paying for expensive drugs? Let me count the ways ...

1. The formulary. You have prescription drug coverage -- that doesn't mean that your insurer will pay for every drug that you may ever need. It means that they will pay for the drugs that they choose to pay for. This list is called the "formulary." If the insurer wants to shave a bit off their operating expenses, all they have to do is eliminate a few of the most common drugs -- or the most expensive ones.

2. Percentage co-pays. I studied the formulary for one of the expensive drug denials. I noticed that formularies look very different than they did twenty years ago. On this current formulary, the less-expensive drugs had a dollar-amount co-pay -- $10, $20. When the list got to the more expensive drugs, the co-pay magically turned into a percentage. Erbitux, $12,000 per month. Even if the insurer approves it, you will be paying whatever percentage the insurer chooses -- in this case, 40%, or $4,800 per month. That's a pretty hefty price tag, when you are taking Erbitux for recurrent colon cancer, and you can't work.

3. Medical policy statements. On top of these other hidden icebergs, every insurer has hundreds of medical policy statements -- for other medical procedures and treatments, and for expensive drugs. These documents explain all of the reasons why the insurer won't pay for these drugs or medical treatments. Or, they explain which under which limited circumstances they will cover them.

Off-label use

When I delved into these drug cases, I discovered something shocking. After fighting sixty-nine appeals, it takes a lot to shock the Insurance Warrior.

When the FDA approves a drug for sale, it specifies what conditions the drug should be used for. The FDA also states the doctors are welcome to prescribe these drugs for other uses -- "off-label use."

I learned that there is a law on the books stating that Medicare will not pay for drugs which are prescribed for off-label use. What is so shocking about that? One out of every five prescriptions written by doctors in this country is for an off-label use. With one regulation, Medicare gets out of paying for one-fifth of all prescriptions that are written. But it gets worse ...

One out of two prescriptions for cancer drugs are for off-label uses. Plus, cancer drugs are the most expensive drugs. What a great cost-savings! With one law, Medicare gets out of paying for one-half of all prescriptions for these pesky expensive cancer drugs!

As of this year, private insurers denying more expensive drugs, and invoking Medicare rules as the reason for their denials.

Ignoring the medical policy

I recently received an email from Jim in California: "Anthem Blue Cross of California denied Avastin, my wife's treatment is supposed to start next week. Can you help?" Anthem's denial stated that Avastin "is experimental for this condition." Jim's wife was diagnosed with primary peritoneal cancer.

I found Anthem's medical policy statement for Bevacizumab (Avastin) on their website. It took me five minutes to find the list of diagnosis codes for which they would approve Avastin. Lo and behold, there it was: "158.0-158.9 -- Malignant neoplasm of the retroperitoneum and peritoneum."

Anthem had denied Avastin for a use that was expressly allowed in their own medical policy statement.

I sent Jim a copy of the med policy, and told him to point this out to his doctor, and to put that page of the medical policy statement in front of the correct decision-makers at Anthem. Anthem immediately approved the drug.

There are two possibilities of what happened there; both are equally bad:

Anthem doesn't bother to read their own medical policies before denying a treatment.

Anthem knows full well that they approve this drug for this use. They bet on the fact that neither the patient nor his doctor will never find the medical policy statement.

Compendia

Which brings me to the most cruelest tool in Medicare's arsenal -- the compendia. The compendia are so cruel, because they look like something that will help us.

Medicare will cover anti-cancer drugs for off-label use -- if they are mentioned positively for the requested use in one of four designated drug compendia. Of course, these encyclopedias of prescription drugs are published by private companies, nobody is overseeing what they publish, and they each contradict the other. But that's not the worst of it.

When your $12,000 per month Erbitux is denied, you can simply look it up in one of the compendia, find a positive mention about it for your condition, and report this to the insurer, right? No, wrong. Joke's on you. Nobody has the compendia.

Your doctor doesn't have the compendia. The public library doesn't have the compendia. Your local medical school library doesn't have the compendia. Amazon has copies of one of the four compendia; it costs over $300, and is three years out of date.

In one of the drug cases, my helpee had a fast-moving cancer. She had already been through all of the usual chemotherapies. Her doctor had prescribed Sutent, and the insurer had denied it for her disease.

Sutent is made by Pfizer. When I found out that my helpee's sister-in-law works for Pfizer, I said, "Eureka, we have an inside track!" I assumed that Pfizer -- a drug manufacturer -- would have ready access to all of the four compendia that dictate what drugs get paid for by insurers. The sister-in-law could look up Sutent, find a couple of positive mentions, and it would be a slam dunk.

Guess what? Drug companies do not have the compendia.

Do you really think that the average cancer patient in immediate need of a cancer drug will be able to dig up these books, when the combined efforts of the Insurance Warrior and a scientist at a drug company couldn't produce them?

It's so cruel that it boggles the mind. Perhaps if these drugs didn't cost so much, the payors wouldn't have to go to such extravagant lengths not to pay for them.

Happy and peaceful Insurance Warrior-ing,

Laurie Todd

Jstuckey

01-26-2011, 12:29 PM

Interesting and frustrating.

Any knowledge of how an insurance company can deny and say "investigational" when it was FDA approved over 6 years ago? At what point do they switch off "investigational" and consider approving a device? Is there any logic to making that decision, or is there absolutely nothing concrete? Sent my 4th appeal, and waiting on my 4th denial right now, but hoping, by some miracle, I've sent my pre-authorization company (Med-Cert) the studies that prove ADR is no longer investigational. Then I'll probably have to move to the next step of battling the insurance company themselves, even if pre-authorized!

Ready to head to the UK....

Harrison

02-24-2011, 05:43 PM

The Insurance Intelligencer
"You can't appeal it, because we didn't deny it:"
The case of little Oliver

Most of the cases that I write appeals for these days are not denials. I am appealing treatments that have been approved. How can this be?

I am appealing expensive surgeries and treatments that have been approved at the out-of-network rate.

In a PPO plan, you pay more for monthly premiums, co-pays, co-insurances, out-of-pocket expenditures. You pay more for everything. You pay all this so that you can go anywhere you want for treatment, and your insurer will pay 80%. That's how a PPO works, right?

Wrong. Joke's on you. You just got sucked in by the biggest con game in the history of health insurance. People who blithely go for expensive out-of-network treatments or surgeries just climbed on the slippery slope to the poorhouse.

A PPO approval is the same as a denial

Why am I not seeing so many outright denials these days? Because you can appeal a denial ... and you may win. Insurers don't want to devote resources to dealing with appeals, and they don't want to pay for expensive treatments. How to shut the door firmly, without leaving you any recourse?

Thus was born the PPO. Make the insured people believe that "they can go anywhere," and "we will pay 80%." Make them pay more for everything -- higher monthly premiums, higher co-pays, higher co-insurances. When expensive out-of-network treatment or surgery is needed, send a letter that says, "Treatment APPROVED!" Just don't tell them what you are going to pay 80% OF. Keep that a huge secret. Just tell them it's approved.

Make sure that they go into that surgery believing that it's all taken care of. As long as they stay ignorant until after the surgery date, you're home free ... because after the surgery, they're sick, they're weak, the bills are going out. They have lost their leverage, and you won't have to pay for it.

Finally, the doctors -- who have been paid $400 for a $30,000 surgery -- start balance-billing the patients. You can then blame their problems on the "greedy doctors."

Brilliant.

Little Oliver needs his head fixed

Which brings me to the case of little Oliver in California. I have written eight appeals for children with craniosynostosis. These children are born with one or more of the sutures of the skull prematurely fused. The minute these sutures fuse, the head -- and brain -- is prevented from growing in the right directions, and it starts growing in the wrong directions. This results in an unusual appearance, and scary possibilities for the brain if not correctly treated.

The surgery to fix these children's little heads is a mixture of art and science. Insurance companies would just as soon have you take your child to the local in-network plastic surgeon who specializes in breast enhancements and liposuction, rather than a pediatric craniofacial surgeon who specializes in this condition. Hey, he's an M.D. That's good enough for the insurance company.

Think you will never need out-of-network treatment? Do you believe that every surgeon with an M.D. is created equal, and every treatment that you could possibly need from cradle to grave is available locally, and in the insurance network? Say that to me again, when you are diagnosed with a difficult brain tumor, and none of the local talent have the skills to remove it.

Oliver's insurance company -- Anthem Blue Cross of California -- has approved his surgery with out-of-network craniofacial surgeon Dr. Fearon in Texas. Only problem? They have approved it at the "out-of-network" rate.

Insurers will fight to the death any attempt to get them to reveal how much they will be paying. However, around the time that Oliver's case came up, a Blue Cross and Blue Shield company revealed how much they were planning to pay Dr. Fearon for this surgery. The billed charge for Dr. Fearon and his assisting surgeon combined is about $28,000. Blue Cross and Blue Shield approved the surgery as out-of-network, and planned to pay $1,000 for it. The patient would be responsible for the $27,000 that they didn't pay. This is really how little they pay.

Sound lke good coverage to you? Let's say you have a $28,000 car, and full coverage with your auto insurer. The car is totalled, and the insurer gives you a check for $1,000. Are you outraged? Are you hollering and screaming at everyone who will listen? Why are people not hollering and screaming about this cruel scam that is the PPO?

How to appeal the approval

If the insurer says that I can't appeal, that is not going to stop me. It's easy -- I just don't call it an "appeal." I call it a "request for reconsideration."

It's all about the words. Treatments are denied with words. Denials are overturned by taking the insurer's words, and turning them to our advantage.

As I look back on it, the plain old denials were a whole lot easier to fight than these deceptive approvals. I have always had to get up very early in the morning to get ahead of insurance company words. In 2011, I have to get up in the middle of the night.

That's exceedingly OK. I will rest when the case is won, the expert surgeon is paid fairly for his work, and the child is home sleeping in his own bed -- with a perfect, round head.

After a few days in the trenches, we won Oliver's "Urgent Expedited Request for Reconsideration." He had his surgery last Wednesday, and is happily playing at home in California with his friends, and his favorite goats. The big challenge for his parents is to keep him from running around and being too rambunctious, as they are keen to protect his perfect head.

Peaceful Insurance Warrior-ing,

Laurie Todd
health insurance help (http://www.theinsurancewarrior.com/)

Harrison

03-23-2011, 01:10 PM

The Insurance Intelligencer 3/23/11
Appeal #71: Brandon's story

We accept insurance "networks" as a given. They are not a given; they were invented forty years ago by insurance companies.

Most of the appeals that I fight nowadays are not for denials -- I am fighting out-of-network APPROVALS. Did you know that it is possible to appeal an approval? Or that, if you are going out-of-network for something expensive, you had better appeal it. Why? Because PPOs are a deception. They compute their "70%" or "80%" based not on billed charges, but on a secret number which they themselves come up with. An out-of-network approval is no better than a denial.

All PPOs are essentially the same as HMOs. You can go wherever you want, and go broke doing it.

Networks are the mechanism by which insurance companies control what treatments they will pay for, how much they will pay for them, and who we may go to for these treatments. What effect forty years of "networks" has on the quality of medical care?

I just won appeal #71, for a 34-year-old man named Brandon. He has a two-year-old son, and a baby on the way. Brandon had the same cancer that I did -- late-stage, metastasized appendix cancer. He needed to get to Dr. Sugarbaker in Washington, D.C.

Dr. Sugarbaker saw Brandon on Friday, it was decided that he couldn't wait, and the surgery was scheduled for the following Wednesday -- five days later.

Why the hurry? Because of what Brandon's in-network surgeon had been doing to him for four years ...

The worst bad medical story

I ask each of my helpees to write a three-page story of what happened to them since they first went to the doctor with symptoms. Names, dates. What they asked, what the doctor said, what the doctor did, how it turned out. I call this the Bad Medical Story.

During the process of discussing Brandon's story with him over the phone, I realized in one moment that this was the most shocking story of all of my seventy-one appeals. Nobody knew how bad this story was, until I interviewed Brandon about his story on Saturday morning.

I was asking questions, and Brandon was looking at his medical records. He said, "Oh, I found a pathology report." I asked him to read it to me. The report stated clearly -- in six different ways -- that Brandon had a low-grade appendiceal malignancy, with a serious risk of metastasis.

Brandon was first told that he had cancer in January 2011. I assumed that the report would be from 2011.

"The report is dated 5/2/07," he replied. The report concluded: "This report was delivered to Dr. Anderson* on 5/2/07." Brandon didn't make the connection until I said, "Brandon ... your doctor knew that you had cancer in 2007." The silence was so great ... I could hear my own heart beating.

Brandon's four-year saga passed before me: Appendectomy in April 2007. Visit to Dr. Anderson a few weeks later to hear the results of the pathology report. Dr. Anderson saying, "The report is inconclusive. Don't worry about it."

Brandon returns to Dr. Anderson many times over the next four years -- complaining of pain in the lower abdomen, bloating, nausea. Dr. Anderson tells him that he has acid reflux, prescribes Prilosec, and says, "Come back and see me in a year." Six months later, Brandon comes back in with worse pain. Dr. Anderson says, "You have gall bladder trouble, but you don't have enough pain to justify removing it. Come back and see me in six months."

And so on, until January of 2011, when Dr. Anderson finally agrees to remove Brandon's gall bladder. He comes to the hospital room after the surgery, and says, "You have tumors. You have cancer. But don't worry, it can be taken care of. I asked some people, and we have to get you to Dr. Sugarbaker. He is the only one who gets good results with these advanced cases."

The insurance company proceeded to deny the referral to Dr. Sugarbaker ... because he is out of network.

Making them pay

The Bad Medical Story was the star of this appeal. I called that section, "Cancer diagnosis concealed for four years."

I also proved that the in-network surgeon who they would compel him to see had no qualifications, experience, or training in the complex surgery which was at issue. Further, this in-network surgeon was not offering the same surgery or heated intraperitoneal chemotherapy as Dr. Sugarbaker. I dug up a newspaper article from 2006, announcing that Dr. In-network had just performed this exciting new treatment on three patients. Guess what I found, when I went looking for them? Obituaries. All three patients had died within six months of their surgeries with Dr. In-Network.

I wrote the appeal over the weekend. Late Sunday night, I faxed and emailed it to all of the top executives of the insurance company. By Tuesday at 11:00 a.m., the insurer had signed a single-case agreement with Dr. Sugarbaker's office.

Brandon had his surgery on Thursday. Dr. Sugarbaker was able to remove all of the cancer, and he is doing very well.

All networks must go

Some of the finest physicians with the very best outcomes have dropped their contracts with insurance companies. The first one to go is always Blue Cross Blue Shield. Why? Because Blue Cross Blue Shield's reimbursement is the most insultingly low, and they have the most paperwork. What good is your network, if the one surgeon who can remove your child's brain tumor is not in it?

I have heard of doctors being fined or reprimanded by the insurance company for referring patients out-of-network. What kind of a system is it that tolerates and protects bad medical care, and denies extraordinary medical care?

It is a system that ignores evidence-based medicine -- while pretending to practice it. A system that has no investment in good outcomes for patients. In what universe is it OK to wait four years to treat a cancer, then to deny the one treatment, then to deny the one treatment that could save his life?

Brandon's story is happening right now, in your town. Today, primary care physicians will be referrring more patients to Dr. Anderson -- because he is the in-network surgeon on their list.

I was referred to an unqualified and inexperienced surgeon six years ago here in Seattle -- because he was contracted with the insurance company. He stopped performing these complex abdominal surgeries in 2008, because he "wasn't happy with his mortality rate." He started doing them again six months later, because there was nobody else in the network to do it. How easily I could have been one of his casualties.

These networks are all about abuse and deception. The only ones who benefit from "networks" are insurance companies. If I had my way, I would forget the 1,000-page healthcare bills, and abolish all networks tomorrow.

Peaceful but passionate Insurance Warrior-ing,

Laurie Todd
health insurance help (http://www.theinsurancewarrior.com/)

Harrison

04-27-2011, 08:43 PM

The Insurance Intelligencer
4/28/11

The Agency for Healthcare Research and Quality: No agency, no research, no quality

Insurance company words always mean the opposite of what they appear to mean:

"Blue Cross and Blue Shield" is not on a sacred (cross) mission to protect (shield) us from danger.

"Reasonable and customary" reimubursement is "unreasonable and unusual."

The job of the "Rapid Response Resolution Team" is to never under any circumstances call you back.

We are going to see what happens when government words join with insurance company words -- for the sole purpose of denying your treatment. Hang onto your pocketbooks, it's a wild ride ...

*****

AHRQ: What is it?

I was studying Anthem's Medical Policy Statement for bioimpedence spectroscopy the other day.

The policy declared this test "experimental." I went directly to the "Government and other agencies" section, to see which groups they used to justify their negative policy. I was expecting to find one of the usual questionable suspects there -- Hayes (a private company), NCCN (a private company), NICE (guidelines from the UK).

I only found one entity who is supposedly "against" this medical test: The Agency for Healthcare Research and Quality. My first thought was, as always, "Who are these people?" They sounded like a government entity. Were they?

It took me about ten minutes to discover that "AHRQ" means the opposite of what it appears to mean:

Agency: The guidelines put out by this supposed impartial "agency" are written by private companies -- with no government oversight.

Research: No research is done by the AHRQ. They simply use information from private, for-profit companies.

Quality: The AHRQ could not possibly judge the quality of treatments -- because they have no measure for what "quality" is.

The AHRQ goes to great lengths to paint themselves as a busy beehive of activity. We imagine the world's best medical researchers, studying all manner of treatments in gleaming laboratories, and giving their expert, unbiased opinions on which treatments your insurance company needs to pay for.

Guess what? There are no scientists, there are no laboratories, there is no research. The Agency for Healthcare Research and Quality does not DO anything.

The EPCs: Who are they?

There are many private guidelines companies who cater to insurance companies -- Hayes Technology Assessments, NCCN Guidelines, Milliman Guidelines, and so on. I have read a number of these guidelines; I have never found one that had any scientific validity. These companies exist to provide insurance companies and other payors with documents which help justify treatment denials. Their names sound official, and most people never actually read the guidelines, to see if there is any real substance to them.

However ... a few of us out here are getting hip to the obvious bias -- and lack of real science -- in these guidelines.

This is where the Agency for Healthcare Research and Quality comes in. The AHRQ functions like a money launderer. They take the same old private, biased sources of information, filter it through a nonexistent government entity -- and magically transform it into something that looks respectable, reliable, and impartial. Let's see how it works ...

If the AHRQ doesn't do the research -- then who does the research? The AHRQ has designated fourteen "Evidence-Based Practice Centers (EPCs)." The EPCs write the guidelines. Then, these privately produced guidelines are turned into "Evidence-Based Practice Guidelines."

"Evidence-based" is one of those insurance company words; it means the opposite of what it appears to mean. When you see a website slinging the phrase "evidence-based" around the way they do on this AHRQ website ... you know that somebody is trying a little too hard to convince you.

It has been my experience that anything called "evidence-based" by insurers really has no evidence behind it at all. Newsflash: Insurance companies are not practicing evidence-based medicine, they know that they are not practicing evidence-based medicine, and they are not concerned about whether or not you receive treatments for which there is any proof or evidence.

In my appeals, I provide a hundred times more evidence that the insurer could provide for many treatments which they routinely offer.

We have followed the thread from the ultra-official-looking AHRQ government website -- all the way to the EPCs. Who are these so-called Evidence-Based Practice Centers, the ones who provide all of the proof/evidence/research which decides which treatments our insurers will allow us to have? The first of the fourteen Evidence-Based Practice Centers is ...

BLUE CROSS AND BLUE SHIELD ASSOCIATION

Huh??? An insurance company gets to write guidelines that determine what treatments insurance companies will have to pay for? With a government agency acting as the go-between to make their pronouncements seem impartial, substantial, and acceptable? Since when is Blue Cross Blue Shield a "practice center"? The last time I checked, Blue Cross and Blue Shield was an insurance company -- not a medical center or research laboratory.

The government just put the fox in charge of the hen house. I thought that you might want to know.

Peaceful Insurance Warrior-ing,

Laurie Todd
health insurance help (http://www.theinsurancewarrior.com/)

Harrison

05-26-2011, 08:20 PM

The Insurance Intelligencer - 5/25/11

"Experimental -- for this particular patient"

What if your insurance company denied a lifesaving treatment because it was "experimental" for you, just you, and nobody else but you?

In the case of Patricia from New Jersey, that is exactly what happened.

The denial

Two weeks ago, I heard from Abbie in New Jersey. Her mother Patricia had been diagnosed with appendix cancer, and she needed the same treatment that I had six years ago -- cytoreductive surgery and heated intraperitoneal chemotherapy (HIPEC). Horizon BC/BS had denied the surgery as experimental. Not experimental in general, and not experimental for appendix cancer. Experimental for just this one patient.

Experimental for one patient, but OK for everyone else? Absurd.

Patricia has a sub-type of appendix cancer that is so rare that my expert surgeon has only seen twenty cases of it -- out of two thousand surgeries: adenocarcinoid with goblet cell or signet cell morphology.

The denial says:

This treatment has no proven benefit for the particular diagnosis or treatment of a patient's particular condition.

Not generally recognized by the medical community as safe or effective for the patient's particular diagnosis or treatment of the patient's particular condition.

I could hear the insurance company saying, "This patient has a really rare cell type. Let's call the treatment experimental for that particular cell type. She will never figure it out. There are so few patients with this cell type -- she will never find any studies or proof for that type in particular. Easy denial, slam dunk!"

Not that easy. I was about to immerse myself in the murky swamp of appendix cancer pathologies and terminology...

Is it appendix cancer?

Horizon BC/BS's medical policy statement for cytoreductive surgery and HIPEC says: "This treatment is medically necessary for pseudomyxoma peritonei. It is experimental for all other conditions."

In this denial, Horizon BC/BS exploits the great confusion surrounding the terminology used to describe appendix cancer. Even the experts don't agree on what the words mean.

Some use the term "pseudomyxoma peritonei" as an umbrella term, to cover all types of appendix cancer. Some use the term just to refer to the less aggressive forms of appendix cancer. And some use it just to refer to the mucin which is produced in great quantities in the less aggressive forms of appendix cancer.

How did I prove it?

Insurers don't care if we need a treatment. They do not care if our doctors believe that we need a treatment. They don't care if it is a tried and proven treatment, or if it is the only treatment that will save our lives.

There is only one question that insurers care about, when deciding whether or not to pay for a treatment: "Are we required to pay for this, under the terms of your contract?" This is the only question that matters, and we must prove the answer with every word in our appeal.

In this case, how did I prove that they would have to pay?

This particular cell type -- adenocarcinoid with goblet cells -- is a sub-type of the group of mucinous appendiceal cancers called "pseudomyxoma peritonei." The two leading experts on appendix cancer -- Dr. Ronnett at Johns Hopkins, and Dr. Paul Sugarbaker -- agree on this.

Horizon's medical policy #0035 specifically approves this treatment for pseudomyxoma peritonei.

Horizon's medical policy #0035 does not mention this patient's cell type. This medical policy does not state that "this treatment is experimental for adenocarcinoid with goblet and signet cells." It does not mention her cell type at all.

Horizon BC/BS has paid for this treatment for a patient with adenocarcinoid with goblet cells before. I give the patient's name, name of surgeon, and date of surgery.

Horizon BC/BS has approved this treatment seven times -- for all different cell types included under the umbrella term "pseudomyxoma peritonei." I give names and dates for the seven Horizon cases.

All major insurers approve this treatment for this particular cell type. I list eleven cases -- with names and dates -- where insurers have approved this surgery for patients with adenocarcinoid wth goblet cells.

All major insurers pay for all types of appendix cancer. I include my entire list of 115 cases where insurers have paid for all different cell types.

In their denial letter, Horizon invents a whole new definition of "experimental" ("for this particular patient"). I point out to Horizon that, when the contract is in place, they don't get to change the contract.

The reviewer on the denial letter is a family practice physician. I point out that he is not qualified to render an opinion on the treatment which is at issue.

The in-network doctors know nothing about this disease, nor do they know how to treat it. I prove this by telling the Bad Medical Story.

It took me thirty-eight pages to prove this case with facts. I faxed and emailed the appeal on Sunday night. Horizon BC/BS reversed their denial on Tuesday morning.

I have to get up earlier and earlier in the morning, in order to outsmart these insurance companies. I can do it ... but how many others can do it?

How many patients who are suddenly diagnosed with a late-stage cancer -- and whose surgery is denied -- would ever be able to sort out the fine points of pathology, and be able to argue them in an insurance appeal?

(Picture: Mom Patricia is on the left, daughter Abbie in black.
Patricia had her surgery with Dr. Richard Alexander in Baltimore)

It is time for insurance companies to be held accountable for their decisions. There is a bill which has been written in California which will do just that. This bill could change the balance of power between patients, doctors, and the huge monopolies which are modern-day insurance companies. About this bill, more will soon be revealed ...

Happy and Peaceful Insurance Warrior-ing,

Laurie Todd
health insurance help (http://www.theinsurancewarrior.com/)

Harrison

09-06-2011, 11:10 AM

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 (http://www.theinsurancewarrior.com)

Harrison

10-31-2011, 08:55 PM

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 (http://www.theinsurancewarrior.com)

MeggieLynn

10-31-2011, 09:22 PM

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

Harrison

01-10-2012, 12:57 PM

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 (http://hiaa2012.org/)

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 (http://www.theinsurancewarrior.com)

laid up doc

01-10-2012, 01:15 PM

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

03-29-2012, 08:26 PM

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:

Abilify
Klonopin
Lorezapam
Diazepam
Guanfacine
Topamax
Risperdal
Orap
Tetrabenazine
Haldol
Botox
Prozac
Wellbutrin
Zoloft
Strattera
Gabapentin
Vicodin
Oxydodone
Oxycontin
Dilaudid
Roxicet
Tramadol
Prednisone
Lododerm
Hydrocodone
Amrix
Tizanidine
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 (http://www.theinsurancewarrior.com/)

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!

Harrison

06-03-2012, 02:42 PM

Good job, Laurie! Helpful analysis too - especially on the "danger of medical privacy."
______________________

The Insurance Intelligencer 6/4/12

The bigger they are, the quicker they fall

On Wednesday I received a call from Michael and Carrie in Vermont. We have been friends since her surgery with Dr. Sugarbaker in 2009. Her second surgery with Dr. Sugarbaker was scheduled for next Tuesday.

Their insurance company -- MVP, a subsidiary of Cigna -- had been stringing them along for months. Now, one week before the surgery, it was clear that they weren't planning to pay. Cigna had paid for Carrie's first surgery with Dr. Sugarbaker in 2009. It's just that Cigna (masquerading as "MVP") didn't want to pay for it again.

It was clear that I would have to stay up all night and write the appeal on Wednesday night. I would fax and email the appeal to fourteen movers and shakers by 5:00 a.m. Pacific time on Thursday. We would then have to spend all day Thursday on the phone with the appropriate executives.

Michael is insured under a self-funded plan. In a self-funded plan, it is the employer who pays for your medical treatments. Therefore, your employer gets to decide whether or not you will be allowed to have a medical treatment.

Our task was to make Michael's employer reverse their denial within two days. Guess who the employer is? IBM.

In this story, we will see that private medical information is the most powerful weapon that we have to fight insurance denials -- and that this information is the most precious gift that we can give ...

The gift of precedent

By 5:30 p.m., I was knee-deep in Carrie's appeal. All of a sudden, it dawned on me -- I had won a case for an IBM employee for this treatment before.

Back in 2007, Al from New York contacted me. His partner Dan had appendix cancer, and he wanted to Dr. Sardi in Baltimore for surgery. Healthnet had denied it. Same employer as my current case, same disease, different surgeon, different insurance company. All in all, an excellent case of precedent. However, it gets better ...

I called Al. Thankfully, he was home. I told him that my current helpee, Carrie, was going back for a second surgery with Dr. Sugarbaker, and MVP was denying it. I said, "Wait just a doggone minute. Dan had a second surgery last year -- who was the insurance company on that one?" Al replied, "MVP."

But it gets even better. Dan's recurrence was in an unusual place: the lung. His second surgery was with a famous thoracic surgeon in Boston -- Dr. David Sugarbaker, Dr. Paul Sugarbaker's brother.

I couldn't make this stuff up. This is truly the world's most elegant case of precedent.

Slam dunk

Of course, even with Dan's case, 153 other cases of prececent, and a 49-page document -- no employer or insurer ever has to pay for anything. I prepared Michael for the usual full-court press for Thursday -- Michael phoning executives at MVP and Cigna, me coaching behind the scenes, more calls, more strategizing.

Four hours later, IBM and Cigna/MVP decided to pay.

Medical privacy

Over the past forty years, private insurers have waged an all-out propaganda war on the American public. They have been very successful at molding our opinions. Most people believe the following myths:

• Insurance companies will cover our expenses when we get sick.
• If we have health insurance, we are protected from financial ruin.
• Insurance companies are more qualified to make medical decisions than doctors are.
• The main problem with our healthcare system is lazy unhealthy people with bad habits who choose not to have health insurance.
• The other main problem with our healthcare system is greedy doctors.

All unfair, unfounded, and untrue.

With the guidance of insurance companies, we have come to believe that our private medical information is terribly dangerous. Go on any insurance company website. They will assure you up one side and down the other as to how scrupulous they are about protecting your private medical information. The impression is that evil forces are lurking around, just itching to get their hands on your medical information. But never fear! The insurance company is there to protect you!

Ever wonder why insurers are so in love with medical privacy, and medical privacy laws?

When an insurance company denies a treatment as "experimental," or as "not medically necessary" ... it is very embarrassing for them to see on paper that they have paid for it three dozen times before.

Insurance companies despise precedent. It shows that the entire denial/review/appeals process is based on deception.

*****

I have spent seven years building my list of precedent for cytoreductive surgery and HIPEC. I now have 153 cases where insurers have fully funded this treatment -- most of them with out-of-network, out-of-area medical providers. First name, last name, diagnosis, date of surgery, name of surgeon, name of insurance company.

I love my list of precedent for CRS/HIPEC. I include all 153 cases with every appeal for this issue -- rearranged depending upon which disease the person has, and who is the insurance company. Whenever I retool and use my list, I think of the precious helpees and friends who have come before. Their cases go on to help others. My precedent list is a powerful tribute to them.

Insurance companies despise precedent. They have gone to great lengths over the past forty years to persuade us that we must never reveal it. I say: Learn to love your private medical information. It is the most powerful tool you have, in order to help others to access the legitimate, clinically-appropriate treatments which insurers have paid for so many times before.

I will put my medical info out on the Internet. I will hand it out on the street corner, if it will help one other patient.

It pains me to see an entire country succumb to propaganda. Propaganda so pervasive, so expertly deployed, so accepted, so believed. Proganda so powerful that it disempowers us in the very moment when we need every bit of our free will and critical thinking in order to save our own lives.

Remember Al and Dan, my helpees from 2007? Dan died last year. I knew that I could call Al and talk about precedent because we are friends -- and because of his generous heart.

This is not about private medical information. This is about truth. This is about justice. This is about overcoming fear, and about reaching out a hand to help.

Peaceful Insurance Warrior-ing,

Laurie Todd
health insurance help (http://www.theinsurancewarrior.com)

Harrison

04-29-2013, 08:57 PM

The Insurance Intelligencer
4/29/13

The Insurance Warrior is back, ready to fight for truth and justice ...

Doctors who work for insurance companies

When I needed a complex lifesaving surgery -- one which required special training, skill and experience -- my only question was, "Who is the most qualified surgeon, with the best longterm outcomes?" I assumed that this would be first priority for everyone. I was wrong.

For most patients -- the first question is not, "Who is most qualified?" but, "Who will my insurance company allow me to see?" For me, checking with the insurer about where to go for treatment is like conferring with the fox about how to guard the henhouse.

Patients look to their insurers when making medical decisions. This tells me that the American public believes that ...

• Insurance companies would never be deceptive.
• Insurers have our best interests at heart.
• Insurers are great repositories of scientific and medical knowledge.

One of the powerful ways that insurance companies persuade us of their medical knowledge and good intentions is to employ doctors -- and to use these doctors to interface with both you and your treating physician. Who are these doctors, and what is their real job at the insurance company?

What does a "medical director" direct?

Remember the Ministry of Truth in George Orwell's novel "1984"? It was the propaganda machine that taught the people that war is peace, ignorance is wisdom, and obedience is power. And so it is with insurance companies. Insurance company words always mean the opposite of what they appear to mean.

The denial letter from your insurance company is signed by a "medical director." This title is meant to make him sound very medical and very important. It fools patients, and it fools the most sophisticated doctors. It is meant to create the illusion that an expert and important medical executive has really burned the midnight oil studying up on your requested treatment. After all of this due diligence, he has determined in his infinite wisdom that the treatment is just not safe or right for you. In other words, the treatment which your doctor has requested is either "experimental," or "not medically necessary."

Your doctor has requested the treatment. So the insurer pits doctor against doctor. And their doctor is more important, because he is a "director." Makes him sound like he is in charge of the Mayo Clinic, doesn't it?

Well, guess what? Medical directors don't direct anything. They are the peons of the insurance world. And the denial letters which they sign are boiler-plate, identical, generated by computer. There is no due diligence, the emperor has no clothes.
As a matter of fact, they don't even "direct" their own decisons. A medical director once confessed to one of my helpees, "You will get another denial -- but don't worry about it. As a medical director, I am not authorized to do anything but state the insurance company's position."

Whoa. Think about that for a minute. Your so-called "medical director" is not authorized to reverse denials. Any dealings that you have with him are a waste of time. Most medical directors are part-timers at the insurance company. They simply rent out their name and title -- to be displayed on denial letters.

The peer-to-peer review

How do insurance companies get doctors to give up medical decision-making power -- and to deny based not on medical judgement, but on the wishes of the insurance company? They begin by hiring doctors who are not qualified to render an opinion on the treatment which has been requested. Hey, if the doctor had any knowledge or experience with any of these treatments, they might be tempted to approve them.

99% of insurance company doctors are family practice physicians. Family practice physicians have no particular area of specialization -- and are not experienced in or knowledgeable about the treatments which they deny.

So, when you hear that the medical director at the insurance company is calling your doctor for a "peer-to-peer review" -- he is not a peer, and it is not a review. He is calling to tell your doctor all of the reasons why the insurance company isn't going to pay for your treatment.

The "outside expert"

After the insurance company doctor denies your treatment again, they will send your case to an "outside expert." The insurer will tell you that there is a panel of medical experts at the independent review organization which will carefully examine every aspect of your case.

Newsflash: There are no medical experts, there is no panel, there is no examination.

Our entire medical system ultimately rests on independent review organizations. This is your court of last resort. Guess what? These review orgs are private companies which are not licensed, certified or regulated in any way. They rely on a stable of the most questionable doctors imaginable. Hired guns, as it were.

I once had an "outside reviewer" on one of my appeals for brain surgery. This doctor was supposedly a neurosurgeon. When I searched for him, I found no office, no phone number, no nothing. A current medical license, and that was it. I went on a hunch, and searched his state's Bar Association. Indeed, he had been a neurosurgeon. Not a brain surgeon; he had done back surgeries once upon a time. But it gets worse. Twelve years prior, he had gone to law school. He had been an attorney for twelve years, just keeping the medical license in order to do appeals for review organizations.

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When it comes to insurance company reviews -- I have seen pediatricians reviewing complex cancer surgeries, podiatrists reviewing craniofacial surgery. This is not about a good faith effort to review medical treatments. It is about using doctors to create the appearance of medical expertise -- where none exists.

You, the patient, are the only one who can overturn an insurance denial. Win it within the insurance company, before it ever gets to independent review.

Is the reviewer absurdly inappropriate and unqualified to pass judgement on your lifesaving treatment? The more unqualified, the better -- it will be very motivating to your insurer, when you point this out in your appeal.

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Dr. Jerome Zacks has been so troubled by the use of doctors as "denial-tools" by insurance companies that he has created a petition. This petition asks Congress to hold insurance-company doctors to the same standards as doctors who treat patients. Take a look, and sign if you want to send a powerful message to insurance companies:

Link to the petition follows:
SignOn.org - Uniform Standard of Care for Physicians (http://signon.org/sign/uniform-standard-of-care?source=s.icn.em.cr&mailing_id=11583&%3Br_by=6368874&%3B%3Br_by=4483686&r_by=6372079&%3Bsource=s.icn.em.cr)

Happy and peaceful Insurance Warrior-ing,

Laurie Todd
health insurance help (http://www.theinsurancewarrior.com)