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Old 09-06-2011, 11:10 AM
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Harrison Harrison is offline
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The Insurance Intelligencer
9/2/11

The Five Wise Men

Ever called your insurance company? Call six different people, and you will get six different answers. They will tell you that they never heard of whatever you are asking for, the person that you need to speak to is on vacation, and they don't know the name of their supervisor.

People -- especially people who are ill and actually need something -- become discouraged and exhausted by talking to their insurance companies on the phone. Finally, they give up.

The only people whom we are allowed to talk to at insurance companies are people who know nothing, and who are not decision-makers. Their job is to get rid of us by saying, "Just wait for our letter."

Why then should we ever call the insurance company? To write down all of the ridiculous things that they say -- so that we can put them in our appeal.

The Runaround Story

A winning appeal is not an attempt to prove to the insurance company that you really need a treatment, that the treatment is approved by the FDA, or that this is the only effective treatment for your disease. A winning appeal needs to be so unsettling and unnerving to the insurance company that they want to get rid of it as quickly and completely as possible. The only way to make sure that nobody else ever sees this cringe-worthy document is to immediately pay for your treatment.

You will offer a mountain of scientific evidence for your treatment. However, it is the ridiculous, non-sensical, unreasonable, arbitrrary, deceptive actions of the insurance company -- revealed by you in the most embarrassing manner -- that will win your appeal.

The five nuts from Worcester

Deb has a "Blue HMO" plan with Blue Cross Blue Shield of Massachusetts. In other words, she can only see doctors in the state of Massachusetts who happen to be under contract to her HMO. What happens if she needs a complex and difficult cancer surgery -- and no surgeon in Massachusetts who is a provider for HMO Blue can perform it?

What happens is that BC/BS of Massachusetts sends Deb a letter, informing her that the out-of-network surgery with Dr. Sardi has been denied, because, "the requested service is available in-network." BC/BS of Massachusetts has no idea if this treatment is available in their HMO network or not. They simply say, "it is available in-network" ... and let you exhaust yourself proving them wrong.

I instructed Deb to call BC/BS of Massachusetts, ask for the list of in-network surgeons -- and to write down everything they said. What I wanted was a cringe-worthy story. This is exactly how it looked in Deb's appeal:

1. What is that treatment?

On 8/23/11, I spoke to Tina at BC/BS member services. I explained that I have a recurrence of appendix cancer with liver metastasis, I need cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, and the BC/BS denial letter states that "the requested service is available in-network." I then asked for a list of the in-network surgeons who offer this treatment.

Tina asked, "What is that treatment?" She then placed me on hold for twenty minutes. When she returned, she gave me the address of the appeals department, and suggested that I write an appeal.


2. Cut off

On 8/24/ll, I called and spoke with Shayna Thompson. Once again, I explained my condition and the requested treatment, and asked for in-network providers who could perform it.

Shayna put me on hold. I waited on the line for twenty minutes, at which time the call was disconnected.


3. "What is it that you have?"

Later on 8/24/11, I spoke with John in member services. I explained my condtion, told him that the BC/BS letter promised that I would find in-network providers who offer cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. John replied with a question, "What is it that you have?"


4. "You have to choose from the following categories ..."

John asked, "What kind of surgeon do you want?" I replied, "How about a surgical oncologist who specializes in gastrointestinal malignancies, and who performs the requested service?"

John replied, "You have to choose one of our categories. We have hand surgeons, orthopedic surgeons, plastic surgeons, thoracic surgeons, vascular surgeons, and general surgeons." I asked, "Do you mean to tell me that you can't narrow it down any more than that?" "No, that's all we have," John replied.


5. The list of five

I said, "Well, since I don't need a hand surgeon, I suppose that we will have to go with a general surgeon."

John gave me the names of five surgeons. They were all at the same address in Worcester: Drs. Timothy Emhoff, Bruce Simon, Janice Lalikos, Demetrious Litwin, and John Kelly.

Dr. Timothy Emhoff is a pediatric surgeon.
Dr. Bruce Simon is a chest surgeon.
Dr. Janice Lalikos is a craniofacial surgeon.

6. "We don't do cancer."

Drs. Litwin and Kelly are both at UMass Endosurgery. Cytoreductive surgery is not an endoscopic procedure. However, I performed my due diligence, and called their office.

I asked, "Do you offer cytoreductive surgery and hyperthermic intraperitoneal chemotherapy?" The nurse replied, "Honey, you need a urologist." When I asked why I would need a urologist, she said, "We don't do cancer."

I asked, "Can you refer me to anyone who does this treatment?" The nurse replied, "You need to talk to your primary care physician, and she can tell you where to go."

Apparently, my requested treatment is not as available as the BC/BS letter might lead one to believe.

At the end of our conversation, I said to John at member services, "I thought that you would give me a list of credible in-network people who actually do this treatment." John replied, "I can't help you find any doctors. You need to look to your primary care physician for guidance; she will be able to find a doctor for you.

My primary care physician -- Dr. Mary Smith* -- has guided and referred me to Dr. Armando Sardi in Baltimore. (See Dr. Smith's referral letter, page xx.)

******

Imagine the Vice President of Health Care Services at BC/BS of Massachusetts reading this rendition about the Five Wise Men of Worcester. He knows that the president of BC/BS of Massachusetts is also reading it, as is the chairman of the board of directors. What is his first thought? I need to get rid of this, so that nobody else sees it. What is the fastest way to get rid of it? To approve it.

It is time to harness your Runaround Story for good, and to use it in your appeal!

Of course, the Runaround Story was but one persuasive section of a 43-page document. I faxed and emailed the appeal on Sunday night ... and we won on Tuesday morning.

Deb will be on her way to Baltimore for her lifesaving surgery next week.

Peaceful Insurance Warrior-ing,

Laurie Todd
health insurance help
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"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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