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Old 03-07-2009, 06:29 PM
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Harrison Harrison is offline
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Lightbulb The Insurance Intelligencer - 3/9/09

Listen up MIDWESTERNERS!

The Insurance Warrior is Coming to CHICAGO!

May 15-16

********

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

The Insurance Intelligencer - 3/9/09


The First Three Things to Do

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

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

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

What People Do


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

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

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

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

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

ONE: Find the Medical Policy Statement

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

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

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

TWO: Study the definitions

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

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

THREE: Understand the appeals procedure

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

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

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

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

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

Happy and peaceful Insurance Warrior-ing,

Laurie Todd

P.S. If any of this is news to you, perhaps my book should be on your shelf.
__________________
"Harrison" - info (at) adrsupport.org
Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
Founder & moderator of ADRSupport - 2004
Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
Creator & producer, Why Am I Still Sick? - 2012
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