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Hello ADRSupport Friends.
Finally, some good news for people looking for assistance with their insurance coverage! For patients that are seeking insurance coverage for their one-level Charite disc replacement, a third-party can assist you throughout the entire process. To start your appeal process, you need only call this number: 800-216-4154 (open M-F, 8:00 am to 5:00 PM). Your case will be “project managed” professionally by people that know the appeals process. There are little to no costs associated with the service. Again, this program is for people for one-level Charite disc replacements at this time. I hope to see other support services in the future, but any progress is welcome in the meantime. Good luck to all of you! |
Thank you for that lead, my good man!
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J, you bet! I hope this program helps people get the most appropriate treatment for their condition. http://adrsupport.org/groupee_common...icon_smile.gif
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Harrison,
Thank you again for this information! I called the appeals provider on Monday & spoke to a reimbursement specialist there who explained the process to me. I received an enrollment form & HIPAA release form within 2 business days. Between all of the research I have already done and this, hopefully I can get the approval that I am looking for. |
As brevity is key to organization, I deleted another topic to consolidate into this one topic. See below.
__________________________________________ Resources for Insurance Appeals A constant problem for patients is the challenge of ADR coverage – some plans cover it and many do not. It seems unfair that there are such differences between plans. In reality, some people have been approved by the same carrier that has denied others! This “rationing” of health care is the end of the road for many; but it need not be so! One can pursue many appeal options before throwing in the towel. For example, Depuy Spine has invested significant resources to the insurance problem and has rolled out useful infotools for ALL patients seeking ADR coverage. It may also be helpful to people seeking other (non-Charite’) devices, so these information services benefit the patient community at large! Resources for Insurance Appeal First: See the wide assortment of information resources available on Depuy Spine’s site: http://www.charitedisc.com/charitede...mbursement.asp There’s also an individual in each state that is chartered to help you – just use the locator! Second: There are members of this community that are both lawyers and patients. A few of them can answer “quick” questions for you, and a few can represent you as a client. Email me and I’ll put you in touch. Third: Members here have suffered through the appeal process, many have succeeded. Read through these previous discussions; feel free to PM or email any of these members. All want to help you, some are busier than others but will try to help you! See below. Getting Insurance in US to pay for Disk Replacement http://adrsupport.org/eve/forums/a/tpc/f/7701036081/m/9...961037081#9961037081 Anyone that has had 2 levels approved please Help! http://adrsupport.org/eve/forums/a/t...1/m/1131077081 Medicare approval of coverage for Charite http://adrsupport.org/eve/forums/a/t...1/m/9901008481 Anyone approved by UHC? http://adrsupport.org/eve/forums/a/t...1/m/5491077081 Blue Cross of CA Approved!!!! http://adrsupport.org/eve/forums/a/t...1/m/7801028081 ___________________________________ fiddle Harrison, I wanted to be sure to thank you for your very informative post about Resources for Insurance Appeals. I recently put together my appeal, and most of what I included came from your suggestions. The Depuy Spine's site was invaluable. I basically followed that outline step-by-step. I appealed to my secondary insurance company. I didn't even bother with Medicare because when I called they told me they don't cover out of the U.S. unless it is an emergency just over the border. My appeal included: 1) the original Letter of Medical Necessity; 2) My letter using the Depuy format giving history, experience, need, etc.; 3) The name and phone number of my primary MD for more consultation if desired (as well as the surgeon); 4) A picture and the name and brief literature about the Activ-L; 5) The generic informational approval letters from two other big insurance companies; 6) The Medicare approval of the Pro-Disc for the population under 60 years old; 7) A copy of a study (I think it was a letteski post of several studies to choose from). I chose the one that seemed to be a study about a NUMBER of studies, so it was more inclusive. I also sent along brief info about the AlphaKlinik where I had my surgery, and compared the two costs U.S. vs. Germany. All in all -- 39 pages. For those who are new to this, I sent it certified mail with a return receipt. And when I filled out the address on the green certified mail slip, I also wrote the number of pages. That way, they can't say, "oh we didn't receive that part of it". I've learned this the hard way. Wanted to share what I did in case others are looking for ideas. Good luck to all those who are requesting coverage. I will let you know my outcome. P.S. They were close, but Germany came out $1000 less compared to a U.S. estimate for a one-level. This is calculated based on all medical needs, the surgery, the doctors, the tests, the meds, the klinik, the therapies, etc. This does not include the airfare, hotel, meal, expenses for a family member and all incidentals. Only medically-related. This message has been edited. Last edited by: fiddle, September 27, 2006 11:18 PM November 21, 2006, 02:07 PM ______________________________________ Harrison Just a reminder that each state has its own procedure to encourage patients to appeal insurance denials. E.g., the state of Mass. spells out their process and provides applications for appeal here: http://www.ago.state.ma.us/sp.cfm?pageid=1137 888-830-6277 Of course, there is also the Mass. Division of Insurance, Consumer Hotline (617) 521-7794. |
As you all know, medical insurance issues about within our community. Insurance companies wield considerable influence in our personal lives, on Capitol Hill and especially with hospitals. Most of us here have gone to bat (battle?) against insurance companies for coverage for our surgical procedures. It’s terrible, and I fear, getting worse.
Enter the “empress of insurance appeals,” or more popularly known as “the insurance warrior,” Laurie Todd. Her expertise is shaped by her own personal experience -- and successes -- as a cancer patient; she now helps patients from all walks of life win coverage for their treatment. Her record to date helping patients is flawless – and I’ve warned her about the lackluster results we patients have experienced! Nonetheless, here are some ideas for patients to consider: 1. Read the book she wrote: Fight Your Health Insurer and Win. You can order this book on her website; perhaps you could request it from your local library. Her site is: http://www.theinsurancewarrior.com/ Laurie was kind enough to offer a chapter of her book, which is attached. 2. Listen or call in to the June 2 Boston show; or maybe you could even hire her for your appeals. 3. Look for her in a future Q & A column in the Cutting Edge forum. And no, I have no business affiliation with Laurie. I am just trying to help you folks get the treatment you need. There will always be new treatments that are considered “experimental,” so we may need an army of Lauries…. Laurie, knock ‘em dead! I hope this post helps all involved. |
Harrison, thank-you for that information. I am going out today and buy that book! http://adrsupport.org/groupee_common...icon_smile.gif
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Harrison, can you only purchase this book from her website? Not available at Borders or Barnes & Noble? I stopped at one local bookstore yesterday, and their search on the computer brought up nothing. (gotta get my hands on this book!) http://adrsupport.org/groupee_common...on_biggrin.gif
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CindyLou,
This book hasn't been published yet according to Barnes & Noble.Com. I should be released on July 28 according to their website. You can pre-order the book from the site as well. Here is the link: http://search.barnesandnoble.com/booksearch/results.asp...Win&z=y&cds2Pid=9481 The ISBN # is ISBN: 0979143500 Hope that helps! |
Hi, new ADR friends. The Insurance Warrior is in the house.
I published the book myself, I have 4,500 of them right here on the premises, and I sell it from my website www.theinsurancewarrior.com Borders, Barnes & Noble, Amazon are all pretty much money pits for authors. They are not much interested in self-published books unless the author is hooked up with a major distributor, and major distributors take another huge cut, and aren't much interested in self-published authors. If I sell the book to you directly, I get to keep $14.95. If I sell it through a major chain with a distributor involved, I would be lucky to clear about $1 to $1.50 per book. I fervently desire to continue being the Insurance Warrior, keep raising these issues publicly, keep helping folks to win their appeals. So, for now, I keep it all simple and cost-effective. These appeals are not won because we prove that our cases are just, and they are not won because we provide the best information. They are won by intimidation! It is pretty much a huge bluff-down, designed to make the insurer suspect that we might be a lawyer, know a lawyer, or have a lawyer hiding in the woodpile. Standing strong, hanging tough, being the alpha dog ... that is how we win. We don't take it personally. We are peaceful warriors. We understand that it is their job not to pay, and our job to make them pay. I had a metastasized abdominal cancer, and my oncologist said, "There IS no treatment for your disease. And, even if there were, they wouldn't pay for it." My written appeal was the only thing standing between me an certain death. I spent two months researching, reading lawsuits, scoring all the free legal advice I could score, and turning myself into the finest lawyer that money could buy. I had no money, I had lost my business, I had no influence. I had to win big, which I did. When I got done with them, they eagerly paid every penny. I underwent a second massive surgery, from the world's expert on my appendix cancer. And made them pay every penny of it, including the deductible and out-of-pocket. Must have scared them really, really bad. Obviously, I am not dead. I am exceedingly alive. I see no doctors, I take no medication ... I am fine. Thus far, I remain cancer-free. Plus, I have gone on to help people win over twenty of these cases. Since insurers always present the same objections -- in the same order -- every time, it's really fairly simple. Until now, the appendix cancer people have been the only ones to have their very own Insurance Warrior. Between speaking and helping and shipping books and scratching my head in amazement at All This, I don't have time to participate in a lot of online communities. So, ADR folks, you are the second ones. My best to you, I will weigh in from time to time with a radically different approach to making insurance do our bidding. Laurie the I.W. |
Thank-you Laurie. Welcome aboard! We need you and are grateful for any and all input you can bring our way. Meanwhile, I'll be lining up to buy your book on your website. I am not done with my fight yet against HealthPartners! (btw, people, steer clear of HealthPartners at all costs...they completely suck)
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A New Tactic
I have already learned something from helping with an ADR case ... the health insurers have adopted a new tactic in their efforts to deny. Keep an eye out for it. Bear in mind, I am new to the ADR world. So ... I ask some naive questions. The person that I am helping tells me that she is requesting a "second level" disk. I say, "Wait a minute. They paid for it before. In the cancer world, if they pay for it before, we can generally make them pay for it again." "I did point that out to them," she replied, "They told me that, when they approved it before, they paid by mistake." BY MISTAKE??? This is a new one on me ... the I.W.'s infallible gut-o-meter told me that what we have here is a brand-new objection. Three days later, I was called in on a rare cancer case. Person needed surgery, insurer didn't want to pay for it. Medical Director of Acme Insurance calls the expert surgeon's office, asserting that the surgery is experimental. Expert surgeon's P.A. says, "Acme Insurance, United Healthcare, Aetna, Cigna ... all of them have been paying for this for years." Medical Director replies, "Acme Insurance would never pay for this. If we ever paid for it, we paid by mistake. You must have given us the wrong CPT codes." Right. This surgery plus hospital costs about $200,000. They goofed up and paid for it without meaning to. Picture this. Bean counters at the insurance company sitting around, discussing policy: "These patients are starting to talk to each other. They are presenting us with lists of cases where we have paid before. We need to find some way to counteract this. Let's just say we paid by mistake!" Apparently the memo went out industry-wide. Here is how I handled it. I wrote a letter for these folks -- in the patient's voice, of course. I quoted every absurd, untrue, insulting thing the Medical Director said to the expert surgeon's office. Dragged the whole stinkin' conversation out of the closet. As a cherry on the sundae, I added a few more instances where they told untruths, sent the patient to a local surgeon with no experience who would surely have killed him, etc. I had them fax it to everyone from the Medical Director on down, everyone who is anyone at the employer, and so on. I have shamed and embarrassed customer service people, case managers, and many doctors who told untruths or denied care, but never a Medical Director. My letter (from the patient) should hit the fan tomorrow. The surgery is scheduled for June 4. The usual last-minute cliff-hanger. If somebody at the insurance company says something to you which is absurd, ridiculous, untrue, or contrary to your benefits booklet ... people, that is your gold nugget. They have just given you the most powerful ammo you could have. You are going to quote them in your letter -- word-for-word. The whole idea with these appeals is to make yourself sound so dangerous, such a hot potato, that they pay just to get rid of you. It is really quite strange. Here I am writing all of these letters in the voice of the patient. Or else, patients are using the words from the book. Hopefully it takes a few years before insurance companies start scratching their heads and wondering how all of their insureds suddenly got to be such good writers. So ... if your insurer says that they paid for this before "by mistake," quote them in your letter. It is a ridiculous thing to say. Also, supply a list with patient names, surgeon's names, and surgery dates where they have paid for this before. Make it personal, not just a list of cases that have been paid. Surely four different surgeons' offices couldn't all have submitted the wrong codes. I would have fun with it. If somebody told me that over the phone, I would calmly ask, "So ... you're telling me that Acme Insurance has paid by mistake for many surgeries costing in excess of $50,000? MAY I QUOTE YOU ON THAT?" Go get 'em Laurie the I.W. |
Laurie, I like where you're going w/ your strategy tactics. My problem is my husband's employer is privately owned and self-insured, so basically HealthPartners is just acting in an administrative capacity, it appears, under the guidelines of our 2007 health coverage summary plan. Which btw, has still not been finalized or signed by the company head! Every time they deny my appeals, they remind me "it may be helpful to note that all of HealthPartners' coverage policies are available on our web site at www.healthpartners.com, or by calling Member Services at_______." But, the bitch is, when I go to the website and enter my password, it tells me my coverage policy is not available. Then, I call the member service folks, and they read to me what is covered or not! I don't have a copy in my hands, because it's not signed yet!
For example, I quote from my latest final denial: "Your plan excludes coverage for services that are considered investigative. (this is their only answer every time they deny me..investigative) Although NAME OF EMPLOYER has not yet finalized its 2007 Summary Plan Description (SPD), we anticipate that the benefit provisions, when finalized, will read as follows. Under the heading, Services Not Covered, your SPD reads in part: 2. Procedures, technologies, treatments, facilities, equipment, drugs and devices which are considred investigative, or otherwise not clinically accepted medical services." When they sent my appeal for further review to their medical directors, they said,(in same denial letter as above) "this reviewer confirmed that Artificial Intervertebral Disc Replacement is considered investigative at this time. Additionally, the reviewer asserted that the FDA approved labeling of the ProDisc states that the safety and effectiveness of this device has not been established in patients with the following conditions: pregnancy, morbid obesity, two or more degenerative discs, spondylolisthesis greater than 3 millimeters, or two or more unstable segments. The ProDisc is currently required to undergo a Post Market Study to evaluate its long-term safety and efficacy." I do fall under "two or more degenerative discs" category, but I thought the FDA had approved the ProDisc for 2 levels. I happened to need 3 levels, so went to Germany. But my point is, all of these long winded denial letters, time after time, and yet "the company has not yet finalized its 2007 Summary Plan Description, we anticipate that the benefit provisions, when finalized, will read as follows." How crazy is that? I am being denied on what they anticipate the plan to say, when finalized!! Sorry for the long description. Any advice? |
Oh boy. Maybe I should have left the companys' name off. I don't know how to edit yet. Harrison, could you edit that name out, please? Thanks. Cindylou
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Cindy, see the little pencil eraser in the lower right corner of your posts? That's your ticket to editorial bliss... http://adrsupport.org/groupee_common.../icon_razz.gif
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CindyLou:
Being an impartial, hostile against insurance providers (they provide money to their shareholders) type person, I can say things that you may not be able to. Take www.healthpartners .com insurance, which is indicative of the managed care industry that, unfortunately, started out in Minnesota. Group Health, HealthPartners, Metopolitan Clininc of Counseling (MCC), Share, etc. are managed care industries that operated as for profit organizations. Denying care is what they do best. They deny Substance Abuse and mental health treatment like it's going out of style. CindyLou----If your husband is in management and that high up in the company, someone can call and have them review your file to determine medical necessity. Mine got denied twice and I signed an agreement that wiped out the lien Blue Cross had against my lawsuit by agreeing to not appeal my denial. The insurance salesperson who sells us our Blue Cross insurance for our company is on our board of directors and made the call on my behalf to have them review my case. They paid it in full. Someone from your husband's upper management can call and threaten to send the company's business elsewhere if there is an unfavorable outcome from the insurance. If the company is self-insured like you say, they should be taking care of their own. All-in-all my humble and non-biased opinion. Terry Newton |
Hi CindyLou --
In order to offer specific advice on why your appeals have not succeeded, I would have to see the appeals. Remember, the intention of a written appeal is to intimidate, not to prove nor to inform. Regarding the FDA approval, and what qualifications and caveats there are on it ... we will have to get some enlightenment from someone here who is conversant with it. Let me just say that, in the appeals that I have participated in where the insurer said that some procedure was “not FDA-approved,” we ignored it, listed a lot of similar cases where they had paid, a lot of peer-reviewed articles, letters from in-network doctors, made ourselves sound like scary lawyers, and made them pay anyhow. I acknowledge the insurance company objections, but try not to get too mired down in them. A word or two about “self-funded” plans. We are seeing more and more of them these days. In a self-funded plan, a “third party” administers your benefits, which are paid out of the employer’s bank account. Why the employers go for this option, I do not know. Perhaps they go into it believing that they will be able to better control costs themselves. Some of the terrible consequences that we have seen with self-funded plans: 1. A few employees come down with cancer, and the employer runs out of money before the end of the fiscal year. 2. Employee comes down with cancer, “third party” doesn’t want to pay, employer doesn’t want to pay. Now, you are locked in mortal combat with an insurance company AND your employer ... all while fighting cancer. 3. With both company H.R. department and shadowy “third party” mixed up in it, it is almost impossible to nail down who the decision-makers are. There are, however, great benefits in these self-funded plans ... for the insurance company. First, is this third party payor a real insurance company, or just an administrative entity? If the third party is not an insurance company, then, in the legal sense, your health insurance is NOT CONSIDERED TO BE INSURANCE. In other words, you cannot appeal to the Insurance Commissioner in your state for help. The self-funded plan is not subject to state law regarding health insurance. Your only protection is the applicable federal law, which is HIPPA. Guess how long HIPPA allows for a determination to be made if there is a dispute or appeal? 120 days. However, if the third party is a real insurance company – not just an administrator – they will still be subject to the state’s Insurance Commissioner, and state law. Now to your question of “the employer never gets around to finalizing the insurance plan, and the ‘third party’ will never give me a copy of it.” Honey, I would put all of that in your appeal. I don’t have time to Google all this today, but I believe that, if you call your state’s Insurance Commissioner, they will be able to tell you that there is plenty of law compelling your insurer to provide/disclose total current info about your plan. If I remember HIPPA correctly, they also require this. Remember, these appeals are meant to intimidate, in the legal sense, and leap over specific objections. If I had nothing else to work with, I would seize on this as the centerpiece of my letter to the employer/insurer. Not that it really matters, because the new plan will, of course, deny again based on them calling the procedure “investigational.” However, I believe that you might be able to make a compelling case about them not providing current coverage info, not having a signed policy in place, etc. Torpedos away, Laurie the I.W. |
Thank-you Harrison! http://adrsupport.org/groupee_common...s/icon_eek.gif
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And thank-you Laurie and Terry. The company does use HealthPartners only in an administrative capacity, so I cannot go to the state level. Don't think federal is the route either, like you said. I think you nailed it Laurie. Intimidation is my best approach w/ leverage of "no finalized 2007 Summary Plan" yet. And maybe include the comment the owner of co. said to my husband in my husband's private office, when he came to ask how I was: "you know, I could pick up the phone and just tell HP to pay for it." Then obviously changed his mind after meeting with his HR hire who advised him against it. (btw, we found out his top HR person who helps decide what is covered and what is not, HAS HERSELF COVERED UNDER HER HUSBANDS' BENEFIT POLICIES!) Terry, I agree...they should take care of their own, especially since my husband is one of the top exec's and has been with the company for 16 years. My fight is not over! http://adrsupport.org/groupee_common...s/icon_mad.gif
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Getting armed! Just ordered your book, Insurance Warrior. Will wait eagerly for it. http://adrsupport.org/groupee_common...icon_smile.gif
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Oh, almost forgot. Laurie I.W., I sent you an email asking about your fee. Just wanted to make sure you saw it. Thanks.
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I agree, GET MAD!
People who turn that inward just get depressed and the profit-mongers win. They do not expect most people to fight. Most back down as they think the company has bigger and better lawyers. Editorials work nice also as long as you stick to the facts to avoid slander. Don't give them any amunition and use theirs against them. Make yourself a thorn in their sides and they will be throwing money at you. Go with God and a Club! Terry Newton |
Self Funded Plans, regardless of whether they are administered from a Commercial Carrier or a Third Party Adminstrator (TPA), are regulated under a Federal Bill called ERISA. ERISA over rides any state law unless the state law provides for greater benefits to the patient. ERISA provides very specific appeals processes as well as language regarding the Summary Plan Document (SPD). Please see this brief article below taken from the DOL Website. When researching ERISA information, please note that you have to be careful to search for the appropriate and applicable parts, as ERISA also covers many other benefits, such as retirement accounts, etc. I hope those of you that are covered by a Self Insured Plan find this helpful.
U.S. Department of Labor Workers’ Right To Health Plan Information Printer Friendly Version The Employee Retirement Income Security Act (ERISA) governs approximately 2.5 million health benefit plans sponsored by private sector employers nationwide. These plans provide a wide range of medical, surgical, hospital and other health care benefits to some 134 million Americans. Under ERISA, workers and their families are entitled to receive a summary plan description (SPD). The SPD is the primary document that gives information about the plan, what benefits are available under the plan, the rights of participant and beneficiaries under the plan, and how the plan works. Among other information, the SPD of health plans must describe: Cost-sharing provisions, including premiums, deductibles, coinsurance and copayment amounts for which the participant or beneficiary will be responsible Annual or lifetime caps or other limits on benefits under the plan The extent to which preventive services are covered under the plan Whether, and under what circumstances, existing and new drugs are covered under the plan Whether, and under what circumstances, coverage is provided for medical tests, devices and procedures Provisions governing the use of network providers, the composition of provider networks and whether, and under what circumstances, coverage is provided for out-of-network services Conditions or limits on the selection of primary care providers or providers of specialty medical care Conditions or limits applicable to obtaining emergency medical care Provisions requiring preauthorizations or utilization review as a condition to obtaining a benefit or service under the plan The SPD must also explain how plan benefits may be obtained and the process for appealing denied benefits. ERISA also requires that SPDs be updated periodically. Furthermore, ERISA requires disclosure of any material reduction in covered services or benefits to participants and beneficiaries generally within 60 days of the adoption of the change through either a revised SPD or a summary of material modification (SMM). Material changes that do not result in a reduction in covered services or benefits must be disclosed through an SMM or revised SPD not later than 210 days after the end of the plan year in which the change was adopted. The department’s claims procedure regulation describes your right to get an answer from your health plan regarding your health benefit claim. The regulation protects you – providing for a timely response by describing the time frames for a decision, providing for a fair process by describing the standards for a decision, and providing for meaningful disclosure by describing the notice and disclosure that you are entitled to receive from your plan. Look to the SPD for information on your health plan’s claims procedure. This fact sheet has been developed by the U.S. Department of Labor, Employee Benefits Security Administration, Washington, DC 20210. It will be made available in alternate formats upon request: Voice phone: 202.693.8664; TTY: 1.202.501.3911. In addition, the information in this fact sheet constitutes a small entity compliance guide for purposes of the Small Business Regulatory Enforcement Fairness Act of 1996. U.S. Department of Labor Frances Perkins Building 200 Constitution Avenue, NW Washington, DC 20210 1.866.444.3272 TTY: 1.877.889.5627 Contact Us |
Some more good information on ERISA Governed Plans:
U.S. Department of Labor Filing A Claim For Your Health Or Disability Benefits Printer Friendly Version • PDF Version Introduction If you participate in a health plan or a plan that provides disability benefits, you will want to know how to file a claim for your benefits. The steps outlined below describe some of your plan’s obligations and briefly explain the procedures and timelines for filing a health or disability benefits claim. Before you file, however, be aware of the Employee Income Retirement Security Act of 1974 (ERISA), a law that protects your health and disability benefits and sets standards for those who administer your plan. Among other things, the law and rules issued by the Department of Labor include requirements for the processing of benefit claims, the timeline for a decision when you file a claim, and your rights when a claim is denied. You should know that ERISA does not cover some employee benefit plans (such as those sponsored by government entities and most churches). If, however, you are one of the millions of participants and beneficiaries who depend on health or disability benefits from a private-sector employment-based plan, take a few minutes and read on to learn more. Reviewing The Summary Plan Description A key document related to your plan is the summary plan description (SPD). The SPD provides a detailed overview of the plan – how it works, what benefits it provides, and how to file a claim for benefits. It also describes your rights as well as your responsibilities under ERISA and your plan. For some single-employer collectively bargained plans, you should also check the collective bargaining agreement’s claim filing, grievance, and appeal procedures as they may apply to claims for health and disability benefits. Before you apply for health or disability benefits, review the SPD to make sure you meet the plan’s requirements and understand the procedures for filing a claim. Sometimes claims procedures are contained in a separate booklet that is handed out with your SPD. If you do not have a copy of your plan’s SPD or claims procedures, make a written request for one or both to your plan’s administrator. Your plan administrator is required to provide you with a copy. Filing A Claim An important first step is to check your SPD to make sure you meet your plan’s requirements to receive benefits. Your plan might say, for example, that a waiting period must pass before you can enroll and receive benefits or that a dependent is not covered after a certain age. Also, be aware of what your plan requires to file a claim. The SPD or claims procedure booklet must including information on where to file, what to file, and whom to contact if you have questions about your plan, such as the process for providing a required pre-approval for health benefits. Plans cannot charge any filing fees or costs for filing claims and appeals. If, for any reason, that information is not in the SPD or claims procedure booklet, write your plan administrator, your employer’s human resource department (or the office that normally handles claims), or your employer to notify them that you have a claim. Keep a copy of the letter for your records. You may also want to send the letter by certified mail, return receipt requested, so you will have a record that the letter was received and by whom. If it is not you, but an authorized representative who is filing the claim, that person should refer to the SPD and follow your plan’s claims procedure. Your plan may require you to complete a form to name the representative. If it is an emergency situation, the treating physician can automatically become your authorized representative without you having to complete a form When a claim is filed, be sure to keep a copy for your records. Types Of Claims All health and disability benefit claims must be decided within a specific time limit, depending on the type of claim filed. Group health claims are divided into three types: urgent care, pre-service and post-service claims, with the type of claim determining how quickly a decision must be made. The plan must decide what type of claim it is except when a physician determines that the urgent care is needed. Urgent care claims are a special kind of pre-service claim that requires a quicker decision because your health would be threatened if the plan took the normal time permitted to decide a pre-service claim. If a physician with knowledge of your medical condition tells the plan that a pre-service claim is urgent, the plan must treat it as an urgent care claim. Pre-service claims are requests for approval that the plan requires you to obtain before you get medical care, such as preauthorization or a decision on whether a treatment or procedure is medically necessary. Post-service claims are all other claims for benefits under your group health plan, including claims after medical services have been provided, such as requests for reimbursement or payment of the costs of the services provided. Most claims for group health benefits are post-service claims. Disability claims are requests for benefits where the plan must make a determination of disability to decide the claim. Waiting For A Decision On Your Claim As noted, ERISA sets specific periods of time for plans to evaluate your claim and inform you of the decision. The time limits are counted in calendar days, so weekends and holidays are included. These limits do not govern when the benefits must be paid or provided. If you are entitled to benefits, check your SPD for how and when benefits are paid. Plans are required to pay or provide benefits within a reasonable time after a claim is approved. Urgent care claims must be decided as soon as possible, taking into account the medical needs of the patient, but no later than 72 hours after the plan receives the claim. The plan must tell you within 24 hours if more information is needed; you will have no less than 48 hours to respond. Then the plan must decide the claim within 48 hours after the missing information is supplied or the time to supply it has elapsed. The plan cannot extend the time to make the initial decision without your consent. The plan must give you notice that your claim has been granted or denied before the end of the time allotted for the decision. The plan can notify you orally of the benefit determination so long as a written notification is furnished to you no later than three days after the oral notification. Pre-service claims must be decided within a reasonable period of time appropriate to the medical circumstances, but no later than 15 days after the plan has received the claim. The plan may extend the time period up to an additional 15 days if, for reasons beyond the plan’s control, the decision cannot be made within the first 15 days. The plan administrator must notify you prior to the expiration of the first 15-day period, explaining the reason for the delay, requesting any additional information, and advising you when the plan expects to make the decision. If more information is requested, you have at least 45 days to supply it. The plan then must decide the claim no later than 15 days after you supply the additional information or after the period of time allowed to supply it ends, whichever comes first. If the plan wants more time, the plan needs your consent. The plan must give you written notice that your claim has been granted or denied before the end of the time allotted for the decision. Post-service health claims must be decided within a reasonable period of time, but not later than 30 days after the plan has received the claim. If, because of reasons beyond the plan’s control, more time is needed to review your request, the plan may extend the time period up to an additional 15 days. However, the plan administrator has to let you know before the end of the first 30-day period, explaining the reason for the delay, requesting any additional information needed, and advising you when a final decision is expected. If more information is requested, you have at least 45 days to supply it. The claim then must be decided no later than 15 days after you supply the additional information or the period of time given by the plan to do so ends, whichever comes first. The plan needs your consent if it wants more time after its first extension. The plan must give you notice that your claim has been denied in whole or in part (paying less than 100% of the claim) before the end of the time allotted for the decision. Disability claims must be decided within a reasonable period of time, but not later than 45 days after the plan has received the claim. If, because of reasons beyond the plan’s control, more time is needed to review your request, the plan can extend the timeframe up to 30 days. The plan must tell you prior to the end of the first 45-day period that additional time is needed, explaining why, any unresolved issues and additional information needed, and when the plan expects to render a final decision. If more information is requested during either extension period, you will have at least 45 days to supply it. The claim then must be decided no later than 30 days after you supply the additional information or the period of time given by the plan to do so ends, whichever comes first. The plan administrator may extend the time period for up to another 30 days as long as it notifies you before the first extension expires. For any additional extensions, the plan needs your consent. The plan must give you notice whether your claim has been denied before the end of the time allotted for the decision. If your claim is denied, the plan administrator must send you a notice, either in writing or electronically, with a detailed explanation of why your claim was denied and a description of the appeal process. In addition, the plan must include the plan rules, guidelines, protocols, or exclusions (such as medical necessity or experimental treatment) used in the decision or provide you with instructions on how you can request a copy from the plan. The notice may also include a specific request for you to provide the plan with additional information in case you wish to appeal your denial. Appealing A Denied Claim Claims are denied for various reasons. Perhaps the services you received are not covered by your plan. Or, perhaps the plan simply needs more information about your claim. Whatever the reason, you have at least 180 days to file an appeal (check your SPD or claims procedure to see if your plan provides a longer period). Use the information in your claim denial notice in preparing your appeal. You should also be aware that the plan must provide claimants, on request and free of charge, copies of documents, records, and other information relevant to the claim for benefits. The plan also must identify, on your request, any medical or vocational expert whose advice was obtained by the plan. Be sure to include in your appeal all information related to your claim, particularly any additional information or evidence that you want the plan to consider, and get it to the person specified in the denial notice before the end of the 180-day period. Reviewing An Appeal On appeal, your claim must be reviewed by someone new who looks at all of the information submitted and consults with qualified medical professionals if a medical judgment is involved. This reviewer cannot be a subordinate of the person who made the initial decision and must give no consideration to that decision. Plans have specific periods of time within which to review your appeal, depending on the type of claim. Urgent care claims must be reviewed as soon as possible, taking into account the medical needs of the patient, but not later than 72 hours after the plan receives your request to review a denied claim. Pre-service claims must be reviewed within a reasonable period of time appropriate to the medical circumstances, but not later than 30 days after the plan receives your request to review a denied claim. Post-service claims must be reviewed within a reasonable period of time, but not later than 60 days after the plan receives your request to review a denied claim. If a group health plan needs more time, the plan must get your consent. If you do not agree to more time, the plan must complete the review within the permitted time limit. Disability claims must be reviewed within a reasonable period of time, but not later than 45 days after the plan receives your request to review a denied claim. If the plan determines special circumstances exist and an extension is needed, the plan may take up to an additional 45 days to decide the appeal. However, before taking the extension, the plan must notify you in writing during the first 45-day period explaining the special circumstances, and the date by which the plan expects to make the decision. There are two exceptions to these time limits. In general, single-employer collectively bargained plans may use a collectively bargained grievance process for their claims appeal procedure if it has provisions on filing, determination, and review of benefit claims. Multi-employer collectively bargained plans are given special timeframes to allow them to schedule reviews on appeal of post-service claims and disability claims for the regular quarterly meetings of their boards of trustees. If you are a participant in one of those plans and you have questions about your plan’s procedures, you can consult your plan’s SPD or contact the Department of Labor’s Employee Benefits Security Administration (EBSA) at the phone number below. Plans can require you to go through two levels of review of a denied health or disability claim to finish the plan’s claims process. If two levels of review are required, the maximum time for each review generally is half of the time limit permitted for one review. For example, in the case of a group health plan with one appeal level, as noted above, the review of a pre-service claim must be completed within a reasonable period of time appropriate to the medical circumstances but no later than 30 days after the plan gets your appeal. If the plan requires two appeals, each review must be completed within 15 days for pre-service claims. If your claim on appeal is still denied after the first review, the plan has to allow you a reasonable period of time (but not a full 180 days) to file for the second review. Once the final decision on your claim is made, the plan must send you a written explanation of the decision. The notice must be in plain language that can be understood by participants in the plan. It must include all the specific reasons for the denial of your claim on appeal, refer you to the plan provisions on which the decision is based, tell you if the plan has any additional voluntary levels of appeal, explain your right to receive documents that are relevant to your benefit claim free of charge, and describe your rights to seek judicial review of the plan’s decision. If Your Appeal Is Denied If the plan’s final decision denies your claim, you may want to seek legal advice regarding your rights to bring an action in court to challenge the denial. Normally, you must complete your plan’s claim process before filing an action in court to challenge the denial of a claim for benefits. However, if you believe your plan failed to establish or follow a claims procedure consistent with the Department’s rules described in this booklet, you may want to seek legal advice regarding your right to ask a court to review your benefit claim without waiting for a decision from the plan. You also may want to contact the nearest EBSA office about your rights if you believe the plan failed to follow any of ERISA’s requirements in handling your benefit claim. Filing a Claim – Summary Check your plan’s benefits and claims procedure before filing a claim. Read your SPD and contact your plan administrator if you have questions. Once you claim is filed, the maximum allowable waiting period for a decision varies by the type of claim, ranging from 72 hours to 45 days. However, your plan can extend certain time periods but must notify you before doing so. Usually, you will receive a decision within this timeframe. If your claim is denied, you must receive a written notice, including specific information about why your claim was denied and how to file an appeal. You have at least 180 days to request a full and fair review of your denied claim. Use your plan’s appeals procedure and be aware that you may need to gather and submit new evidence or information to help the plan in reviewing the claim. Reviewing your appeal can take between 72 hours and 60 days depending on the type of claim. The law and the Department’s rules allow a disability plan additional time if the plan’s administrator has notified you beforehand of the need for an extension. For an appeal of a health claim, the plan needs your permission for an extension. The plan must send you a written notice, telling you whether the appeal was granted or denied. If the appeal is denied, the written notice must tell you the reason it was denied, describe any additional appeal levels or voluntary appeal procedures offered by the plan, and contain a statement regarding your rights to seek judicial review of the plan’s decision. You may decide to seek legal advice if your claim’s appeal is denied or if the plan failed to establish or follow reasonable claims procedures. If you believe the plan failed to follow ERISA’s requirements, you also may want to contact the nearest EBSA office concerning your rights under ERISA. Resources For the EBSA regional office nearest you or a copy of any EBSA publications, call toll free: 1.866.444.EBSA (3272), or visit EBSA’s Web site at: www.dol.gov/ebsa This publication has been developed by the U.S. Department of Labor, Employee Benefits Security Administration. For a complete list of the agency's publications, call our toll free number at 1.866.444.EBSA (3272). This material will be made available in alternate format upon request: Voice phone: 202.693.8664, TTY: 202.501.3911. This booklet constitutes a small entity compliance guide for purposes of the Small Business Regulatory Enforcement Act of 1996. U.S. Department of Labor Frances Perkins Building 200 Constitution Avenue, NW Washington, DC 20210 1.866.444.3272 TTY: 1.877.889.5627 Contact Us |
Teresa, thanks for sharing this information, which is interesting on a few fronts. Did this info help you with your appeal? How might this help others going forward?
Many thanks. http://adrsupport.org/groupee_common...icon_smile.gif |
Harrison,
My claim is with Workers Compensation, so it does not pertain to my case. I provided this information for those that are covered under a Self Insured Health Plan. I think the information can be used to assist others on this forum for the following reasons: 1. ERISA is very specific about the process and time frames for requesting coverage. The time frames are different for different situations depending on whether it's pre or post care. Members of the forum need to follow the time frames very carefully especially during the appeals process. 2. ERISA governed plans supersede any state statue unless the state statue provides for greater benefit to the patient. Therefore the Insurance Commissioner, etc. are of little help when appealing. 3. ERISA governed plans have very specific rules regarding appeals. What is interesing is that the Adjustors at most TPAs really don't understand ERISA very well. The patient can use the link to the DOL Website or other ERISA Information sites and find specific rules to include in their appeal. This can be very intimidating to the TPA. These information sites also have Consumer Help Tips on what to include in your appeal, etc. 4. The Summary Plan Document is another key piece of your appeal. ERISA has very specific rules about what should be in the SPD, the time frames for advising members of changes to the plan, etc. Patients should obtain and read the SPD and use any information in it to support the appeal. 5. The final decision on appeals lies with the employer because they are self insured. It is wise to provide any information to support your appeal to the employer. The employer is often not aware of your appeal. There are many players in the game: Employer, TPA, PPO, Case Management, Utilization Review. It is important to know which of the players is most influencing your claim. It is important to obtain each players data. You can't fight their data if you don't know what their data says. I specifically posted the ERISA information in response to CindyLou and Laurie. However, I felt it would be helpful to others on the forum. The first question they should ask their employer is: "Are we self insured?" The rules are very different for self insured plans verses a commercial plan. One of the pieces of data that you should use is the cost. Find out the cost of fusion or other procedure that they will authorize and compare it to the cost of ADR. Many times if you show them the cost benefit they will authorize. Don't forget to include costs for hospital, physicians, anesthesiologist, lost time from work, cost of any short or long term disability payments as well as future medical costs. The point that you want to make is that ADR cost is equal to or less than the alternate procedure cost. Your goal here is make the employer question the TPA as to why they are denying payment for the procedure if the cost is less. Your employer should be questioning the TPA as to why they can substantiate a denial for ADR when the alternative procedure costs the same or more. Harrison, please let me know if I can be of further assistance regarding Self Insured Plans. |
Teresa,
Yes, I have seen this site with all this valuable information which Laurie will utilize to our advantage in her fight for me. The only point I would disagree on with you, is that the TPA really only follows the direction from the employer. Not the other way around. The TPA only acts in an administrative capacity. So, know who your enemies are. In my case, it is my husband's employer, hands down. They have not even provided any of us with a Summary Plan Description. They have 30 days to provide that, per my conversation with "the man" at the Dept. of Labor in D.C., who I talked to on Tuesday. All in all, valuable info. Now, back to my own fight! http://adrsupport.org/groupee_common...s/icon_mad.gif |
CindyLou,
You are right on target!! It is the employer that makes the final decision, which is precisely what I said in #5 above. However, the employer is influenced by all the other players which is why you need to know the data they are using to substantiate their denial. As you put it "know who your enemies are." However, often the employer does not know the specifics of the appeal. Therefore, it is your job to provide them (the employer) data that will make them question the "wisdom" of the TPAs recommendation not to pay for the procedure. Quite frankly the easiest way to get the employer's attention, is to show them with hard cold facts that it will save them money. As far as the DOL telling you that they must provide you copy of the SPD within 30 days, please refer to this paragraph which is taken from the DOL article I posted earlier: "ERISA also requires that SPDs be updated periodically. Furthermore, ERISA requires disclosure of any material reduction in covered services or benefits to participants and beneficiaries generally within 60 days of the adoption of the change through either a revised SPD or a summary of material modification (SMM). Material changes that do not result in a reduction in covered services or benefits must be disclosed through an SMM or revised SPD not later than 210 days after the end of the plan year in which the change was adopted." The key here is if the change did not result in a reduction of services or benefits, then they have up to 210 days. So I would suggest you get a copy of the prior year SPD as your starting point. At least you would have something in writing. Many employers have a HR section on their Websites for employees where you find policy and procedures, vacation formulas, grievance policy, etc. I would check there first. If you can not locate it there, then put your request in writing to the HR Director to provide you a copy of the SPD for the prior plan year until such time that the new SPD is published. Also, request any amendments that have been made to the SPD. Most updates/changes are done by Amending the Original SPD which in fact may have been drafted years ago. As an example my employer's SPD was drafted in 2003. There has been no new SPD published; however, there have been many amendments published. |
Teresa, many thanks for the input. Our current coverage was changed to a new company, HealthPartners, who performs in an acting administrator capacity, commencing 1/1/07. And we have never received a copy of the entire Summary Plan Description, nor can it be accessed by going on line. So, I believe that is what the Dept. of Labor man was referring to, when he said "by law" they have 30 days to get me a written copy. I don't believe it would help us to get a copy of last year's SPD, since it was with a different company, unless I just want to look for "patterns" of coverage/non-coverage. Fortunately, I have enlisted the services of The Insurance Warrior to help me wade thru this muck, and get the most persuasive appeal letter in front of their faces soon!
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More information from our good friend -- Laurie Todd!
__________________________ The Insurance Intelligencer 7/16/07 The Three Most Powerful Weapons There are many components to an insurance appeal, and they should all be present to ensure success. The appeal must not be a “letter,” because a letter is not extensive enough, not substantial enough to be persuasive. No letters, they don’t carry enough weight. It must be an APPEAL DOCUMENT, with a title page, table of contents, cover letter, bullet list of facts, attachments, scary mistake-filled medical story, peer-reviewed studies, resume of your doctor-of-choice, cost comparison, and blockbuster conclusion with a call to action. The facts are important, the tone of your writing (solid as a rock, totally dispassionate) is important, every detail of the appearance of your document is important. After participating in a number of these successful appeals, I feel that there are three elements of the appeal that close the deal better than any other. They are the linch-pins of your appeal, they must be there, and they must be polished to perfection, and packed with power. 1. The Quotation Mark People often call me on the phone and tell me about the outrageous things that their doctor or insurance company representative has said to them. Some examples ... “Don’t even bother to appeal, because there is zero chance of it’s being accepted.” “At your age, we don’t need to find out the cause of your rectal bleeding ... we will just give you a transfusion once a week.” “There is no treatment for your disease.” “Yes, we have paid for that surgery before. We paid for it by mistake, so we won’t be paying for yours.” “We lost the fax, we lost the email, the letter got lost in the mail.” “There are NO good outcomes with that surgery (when the only bad thing about the surgery is that it is out of network).” “You don’t need any more surgery (when you really do).” “You need surgery right away (when you ought best wait to see an expert).” “Your husband is one of our highest-paid executives. If we funded the surgery for you, other employees would be jealous.” These are all true examples. When anyone associated with your insurance company – doctor or bean-counter – says something outrageous, they have just handed you a nugget of solid gold. There is nothing more powerful as a naked reporting of what goes on behind closed insurance doors. Don’t tell me these things ... FIRE UP THE QUOTATION MARKS, AND PUT THEM IN YOUR APPEAL! 2. The Carbon Copy Here’s the scenario: You write a beautiful appeal document – chock full of facts and intimidating medical mistakes, loaded with proof. Then, you send as directed by your insurance company, to “Mr. Joe Post Office Box.” You might as well throw your appeal in the trash. Why should Mr. Post Offfice Box help you out? There is nobody to check up on him, no accountability. You must lavish time and effort on the list of important people to whom you will send a copy of your appeal. You will craft your own list, but I have some suggestions. Always copy the Medical Director of the insurance company. Sometimes it takes a little digging to find these people ... your appeal will have more impact just because they know that you were capable of finding a Medical Director. Then, copy a good list of executives at the insurance company. Copy your state’s Insurance Commissioner. Don’t really send him a copy, he doesn’t want to see your appeal. You just want the insurer to know that you know his name – and have probably contacted him. If this is a group policy through your employer, contact the highest HR executive at your company. Did you find any lawsuits against your health insurer while you were Googling? Copy the attorney who won a lawsuit against them ... this is a name that they will recognize. Has your insurer been investigated by the Attorney General of your state? Copy him – another familiar name for your insurer. Copy the head of your state’s medical board. Be realistic with your cc’s ... they know that Oprah isn’t going to be participating in your appeal. The intention is to have your scary appeal land on many powerful desks at once, and to have many higher-ups picking up the phone to call your addressee. Now, Joe Post Office Box cannot ignore your appeal. 3. The Cost Comparison This really is all about money. Your insurer has denied your treatment not because it is experimental, investigational, not medically necessary, or out of network. They have denied because they don’t want to pay for it. The best way to nip this unspoken objection in the bud is to simply prove that the treatment you are proposing will COST LESS than the treatment your insurer is proposing. Since they are probably proposing no treatment at all, and you will get worse without any treatment, this shouldn’t be too hard to prove. Spelling out all of the terrible expensive things that will happen to you if you DON’T get the treatment serves three purposes: It puts the kibosh on their true motivating objection: We are denying your treatment to control our costs. 2. It serves notice to your insurer, in a very subtle way, that you understand what is behind this denial – money. You have already told about your past malpractice-worthy medical story. With the cost-comparison, you get to tell your possible future malpractice-worthy story – if they don’t pay. ************************************************** ********************************************** Reviews Fight Your Health Insurer and Win Laurie Todd Healthwise Publications PO Box 2045, Woodinville, WA 98072 9780979143502, $14.95 www.theinsurancewarrior.com According to Reader's Digest in April of 2006, seven in ten adults who were driven into debt by medical expenses had insurance at the time. Author Laurie Todd had health insurance when she was diagnosed with a rare form of cancer, but in order to obtain the expensive treatment necessary to save her life, she had to battle her insurance company tooth and nail. Fight Your Health Insurer and Win: Secrets of the Insurance Warrior is a distillation of what she learned—a lifesaving, no-nonsense guide written especially for sufferers of cancer and other deadly medical afflictions. Chapters cover how to qualify one's own doctors (and make sure one's provider is not only generally competent, but an expert in one's specific affliction), manage one's own care, find the best care possible for one's disease, and force one's health insurer to bear the full cost (a common practice among insurers is to pay an "out-of-network benefit" that covers only 60%-80% of the cost—which is just not enough when some surgeries can cost, $200,000 or more). Also discussed are how to research the life's work of one's physician on Google and ask him questions about his practice (it's important to listen to the tone of the answers as well as the answers themselves); why terms like "experimental/investigational procedures" and "medically necessary" are little more than manipulative word-dancing meant to frighten away people from demanding insurance payment; how to respectfully and persuasively present one's case to insurance industry bureaucrats and medical professionals who have a vested financial interest in your imminent death (if you die quickly, they don't have to pay for your treatment); and much more. Sample letters, step-by-step procedures, guidelines for telephone conversations, and above all the admonition to never give up infuse Fight Your Health Insurer and Win with literally life-giving energy and wisdom. Highly recommended, and an absolute "must-have" for anyone who has paid their health insurance dues. Susan Bethany Reviewer http://www.midwestbookreview.com/rbw/jul_07.htm#bethany ************************************************** ********************************************** Where to Buy the Book My book is available from my website and several independent bookstores in the Seattle area (University Bookstores, Village Books in Bellingham). No chain stores, none of that. You may order the book by ... Go to www.theinsurancewarrior.com and use the Buy Now button. Call me at 425 497-1858, and I will take your order by phone. Send me a check for $19.95 if you are outside of the state of Washington, and $21.32 if you are in Washington: Healthwise Publications P.O. Box 2045 Woodinville, WA 98072 ************************************************** ********************************************* The Insurance Warrior Speaks – in Public A speaking career seems to be developing naturally, as the book spreads across the country. If you know a group or organization who needs to hear this empowering insurance message, just give me a call. My best, and good Insurance Warrior-ing to all. Laurie Todd laurie (at) theinsurancewarrior.com 425 497-1858 |
Posted for our friend, the author, Laurie Todd.
_________________ The Insurance Intelligencer 8/12/07 Precedent: Proof that Packs a Punch Your health insurer says, “We will not pay.” What facts do you have to prove, in order to make them pay? You will prove many facts in your written appeal: The insurance-contracted doctors have made numerous mistakes. Purpose: Intimidation ... you hold the “malpractice cards.” The mistakes that your insurance doctors made could lead to very expensive bad outcomes. Purpose: To show that you understand that this is all about money. Your treatment-of-choice produces proven good outcomes. Purpose: To compare and contrast with the treatments you have already undergone, which have no chance of a good outcome for you. What you are proposing will cost less than what they are proposing. Purpose: To overcome the underlying objection, which is all about money. You must include as many types of proof as you can, if you expect to win your appeal. However, the most powerful, unassailable, intimidating type of proof which you can provide is PRECEDENT. What is precedent? Proof that they have paid for this before. How do I know that precedent is the most powerful type of proof? Because I can already see health insurers trying to fight back against our predecent. Fortunately, I know how to lob those shells right back over the wall. Where do we find precedent? Let’s say that you have melanoma, you have Acme Insurance, and they won’t pay for an expensive medication. They state that the medicine is “experimental/investigational.” Many patients would stop right there, “Oh well, it’s experimental.” They tell me that it is experimental, but they have already paid for it? How could this be? Remember the Insurance Warrior battle cry: “They aren’t saying that it is experimental because it IS experimental. They are saying that it is experimental because THEY DON’T WANT TO PAY FOR IT.” Because you are an Insurance Warrior, you will leap over this objection. Not only will you find all sorts of peer-reviewed articles and published studies to support your request for this medication, but you will find cases where they have paid for this before. You are not privy to medical records ... how will you find this proof? Simplest way is to join an online support group for melanoma. Join two or three. Find the groups by Googling “melanoma support” ... that you get you started. Also, search through Yahoo Groups ... they probably have a dozen groups for any disease or condition. Get on the groups, introduce yourself, and put out the call: “My name is Mary Smith. My story is such-and-such. I have Acme Insurance, and they don’t want to pay for my Erbitux. Does anyone here have Acme Insurance, and have they paid for Erbitux? Who is your doctor? When did they pay?” Within hours, you should have some precedent. Does the precedent have to be from my insurer? It is best if it is your insurer who has paid for this before. However, the Insurance Warrior always takes whatever she has, and makes it fit. Let’s say you have Acme Insurance, and all you can find is proof that six other insurance companies have paid. Or, you belong to “California TrueHealth.” Truehealth is a giant health insurer, with separate companies in every state of the union. You have been able to find precedent for TrueHealth in eight of these companies, but not for yours in California. Go ahead and use your proof. Hopefully, those six other insurers where huge, nationwide companies. After your list of precedent, you state: “I understand that these are all different insurance entities. However, it simply adds to the mountain of proof that this treatment is now STANDARD OF CARE for this disease.” What does a precedent list look like? I’ll tell you what it DOESN’T look like – a list of insurance companies who paid. A precedent list is a scary, personal, intimidating list of individuals who have already had this paid for: 1. Mary Jones Acme Insurance/Dr. Bill Smith Erbitux paid for 6/15/07 2. Jim Johnson Acme Insurance/Dr. Ricard Peterson Erbitux paid for 7/8/07 ... and so on. Your list should include at least a dozen cases. In the past, there was no Internet. There was no way for patients to discover that, even though their insurer was denying them a treatment, that same insurer had paid for it, for someone else, the week before. Now, the Internet helps to level the playing field. Of course, we do not have access to medical records. I was able to find a dozen cases of my so-called rare cancer at my small local HMO. If I could open up the official database of patients, I would probably have found fifty. Fortunately, we do not need a hundred cases to win ... a dozen will do quite nicely. How are the insurers fighting precedent? Health insurers are very unhappy that we are suddenly able to find out that they have already paid for the medication/treatment/surgery that they have denied to us. This is a real problem, how are they going to overcome it? Just lately, I have noticed two tactics employed to try to avoid paying for you, even though they have already paid for someone else ... Tactic #1: Insurer states: “Yes, we did pay for that before. However, we paid by mistake. We paid by mistake because your doctor gave us the wrong codes (thus inferring that your doctor either made a mistake himself, or is unethical). Pretty lackluster attempt to get out of paying, in my estimation. You go ahead and provide your list of a dozen times your insurer has already paid, and a dozen times the three largest health insurers in the country have paid – over a ten-year period. So .... two dozen different doctors, and all of these insurance companies, have made the same mistake over and over for many years. Not bloody likely. Tactic #2: When appeal succeeds, insurer states: “This is a one-time exception only. We will never pay for this again.” Sorry, Acme Insurance ... you don’t get to do that. We all have the same contract with you. If you provide a service to one contract-holder, you must give the same service to all. You will pay again, that objection is not gonna fly. Find your precedent, compile a long list with names and dates. After you win your own appeal, share this list with all of your friends with the same condition. This is how we become Insurance Warriors ... by winning the battle, then sharing our victories. How to Buy the Book No chain bookstores, none of that. You may order the book by ... Go to www.theinsurancewarrior.com and use the Buy Now button. Call me at 425 497-1858, and I will take your order by phone. Send me a check for $19.95 if you are outside of the state of Washington, and $21.32 if you are in Washington: Healthwise Publications P.O. Box 2045 Woodinville, WA 98072 Good health, and happy Insurance Warrioring! Laurie Todd |
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