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Old 10-27-2007, 04:08 PM
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Harrison Harrison is offline
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Ask the Insurance Warrior
10/21/97

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

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

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

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

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

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

What is an independent review?

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

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

Am I entitled to an independent review?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Buy the book for all of your insured friends at my website: www.theinsurancewarrior.com
__________________
"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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