The Insurance Warrior (Read-only topic)
 

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: health insurance help Laurie was kind enough to offer a chapter of her book, which will be attached to this post soon.

2. Listen or call in to the June 2 Boston show (see above link). She may be able to help you with your appeals too; see her site for contact information.

3. Look for her wisdom 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.

http://adrsupport.org/groupee_common...icon_smile.gif

Attached, please see an excerpt of Laurie's book. I hope this inspires and helps those of you needing guidance through the insurance maze! http://adrsupport.org/groupee_common...icon_smile.gif

Sorry for the late notice, but should you be free now to listen to Laurie on the AM radio, or the web -- she's on for 2 hours!

The Internet:
http://mikerobertswebdesign.com/wcrn/listen.htm
Be patient with the connection...the recording will be archived for future access too.

Saturday, June 2, 11:00 a.m. till 1:00 p.m.
WCRN 830 (am station in Worcester, Mass.)

http://mikerobertswebdesign.com/wcrn/schedule.htm

Michael Savage...we're supposed to believe something on rant radio?


http://img267.imageshack.us/img267/2343/hmob3nv2.jpg
here's the archived MP3 of the Laurie Todd interview. The MP3 will only be up on that website for 1 week. next Sat it will be removed.

I've created a mirror site for everyone who misses this thread and can't grab it soon enough.


1st Hour of Interview
http://www.jumbodir.com/get/?id=8949...f-14771a3e1c51

2nd hour of interview
http://www.jumbodir.com/get/?id=d2bd...d-fa39b230e05a

For those living in the state of Washington:

Laurie Todd is going to speak at the Federal Way and Mercer Island branches of the King Library System on the below dates. This presentation is free. I also think she may be speaking at the Issaquah branch on September 25, 2007 (but check with the branch on this).

See Federal Way Regional Library, Wednesday, August 29, 7pm
Mercer Island Library, Wednesday, November 7, 7pm

Also see link at: http://www.kcls.org/events/author.cfm#todd


Federal Way:
Federal Way Regional
Library
34200 1st Way S., Federal Way, 98003

Mercer Island Library
4400 88th Ave. S.E., Mercer Island, 98040
206-236-3537
253-838-3668

Laurie Todd is speaking at the Issaquah, King County library on September 25th, 2007. It starts at 7:00 pm. Thereafter, she is speaking at the Mercer Island branch as discussed above. Again, these locations are all in western Washington.

Laurie is a great speaker and she has definitely "Been There" and "Done That". What a great resource. She also sells her books at these presentations.

She stated she is 23-0 in assisting others with their appeals. She can no longer afford to help others but I think her track record speaks for itself!!!

Very encouraging.

Thanks epiphaknee, for the update. If you go, give Laurie my best!

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

Ask the Insurance Warrior
10/21/97

The Insurance Warrior Speaks!
Listen to my podcast at www.theinsurancewarrior.com
********************

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

Here's another update from our friend Laurie. Patients and doctors in Arizona may want to check out this event!
________________________

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

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...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

- 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

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
___________________________________________

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.

************************************************** **
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!

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

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

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

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

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

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

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

The Insurance Intelligencer
 

The Insurance Intelligencer : 10/10/08









































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The Insurance Intelligencer - November 5, 2008
 

The Insurance Intelligencer
11/5/08


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


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.



Happy and peaceful Insurance Warrior-ing,

Laurie Todd
www.theinsurancewarrior.com

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.

How about it all?

Time for a new beginning?

Terry Newton

Health Care in America
 

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....

The Insurance Intelligencer: 12/8/08
 

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.


********

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/
ph: 425 497-1858

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/frontl...roundtheworld/

The Insurance Intelligencer - 1/19/09
 

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

Happy and peaceful Insurance Warrior-ing,

Laurie Todd

The Insurance Intelligencer 2/10/09
 

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:


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

The Insurance Intelligencer - 3/9/09
 

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.

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

The Insurance Intelligencer 7/20/09
 

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:

1. 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.
2. 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.
3. 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

"Laurie Live!"
 

The Insurance Intelligencer
8/31/09


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

Greedy doctors, indeed.
 

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-

The Insurance Intelligencer
 

9/20/09


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/

The Insurance Intelligencer October 18, 2009
 

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.


Laurie Todd

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

Except your employer may have no other option
 

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-

The Insurance Intelligencer
 

Well, copyright infringement seems to be a common theme tonight! Any way, Laurie's column is below...thanks Laurie!
___________________________________________

The Insurance Intelligencer
12/28/09

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/

The Insurance Intelligencer - Jan 25th, 2010
 

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

Insurance Intelligencer 3/2/10
 

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!

The Law of Unintended Consequences -- or Intended?
 

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?

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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