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Old 03-29-2012, 08:26 PM
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Harrison Harrison is offline
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The Insurance Intelligencer
3/29/12

Samantha's story

When mom helpees are fighting for their children ... they trust me immediately, jump into my lifeboat without question, and row like crazy. It's a beautiful thing.

The art of waiting

In January I received an email from Lisa in California. Her 14-year-old daughter needed brain surgery.

I thought that this might be a case for me -- so I called Lisa. What I heard was unilike the cancer stories which routinely come across my desk. This was a story of nine years of Big Trouble. It was a story which would both me, bedevil me, and wear on me. However, what drew me to this story was the emotional resilience of one mom -- who had been moving heaven and earth for nine years to make things better for her daughter.

Samantha was diagnosed with severe Tourette syndrome at age six. This means incontrollable, loud, socially embarrassing, exhausting, repetitive vocal and physical behaviors. On and off all day, every day ... for nine years. Tics so violent that they rob her of friends, of school, of a social life. Tics that injure her to the point of broken bones.

I dedicated an entire page in the appeal to the list of medications that this child has been on over the years -- none of which have been effective longterm:
  1. Abilify
  2. Klonopin
  3. Lorezapam
  4. Diazepam
  5. Guanfacine
  6. Topamax
  7. Risperdal
  8. Orap
  9. Tetrabenazine
  10. Haldol
  11. Botox
  12. Prozac
  13. Wellbutrin
  14. Zoloft
  15. Strattera
  16. Gabapentin
  17. Vicodin
  18. Oxydodone
  19. Oxycontin
  20. Dilaudid
  21. Roxicet
  22. Tramadol
  23. Prednisone
  24. Lododerm
  25. Hydrocodone
  26. Amrix
  27. Tizanidine
  28. Hydromorphone
Hundreds of visits over the years to psychologists, psychiatrists, neurologists. Repeated hospitalizations for physical injuries.

The heart of an appeal is the Bad Medical Story. I am used to the Bad Medical Stories of cancer patients -- I had one myself, seven years ago. But this ... so very long, so very hard. This story was an Iron Man triathalon. It was a heavy story to write, much less to live.

Deep brain stimulation has been tried and tested for severe Tourette's. It can work -- when nothing else works. Lisa fought for a year to find a neurosurgeon who would perform this surgery on a 14-year-old. It is routinely done for intractable Tourette's in Europe, but here in the U.S. it is more of a challenge. When she finally found the ideal surgeon -- Dr. Philip Starr at UCSF -- Anthem Blue Cross of California denied it.

I took this case for two reasons. First, this family deserved a break as much as any family that I have ever encountered. Second ... I was moved by mom Lisa. She had been through so much She had found a way to not only fight like a mama lion for nine years ... but to keep it light, keep a sense of humor, keep a family surviving and thriving.

We talked in January. Surgery was scheduled for April 7. I'm sure that Lisa thought that we would immediately start "fighting the insurance company."

I said, "Send me all of the info -- the denial letter, the Bad Medical Story, the proper referral letter from your in-network doctor. I will build a file of the scientific articles, and I will read them. However, we won't be sending this appeal until ten days before the surgery. Anthem would love to have three months to fool around with this case ... but I am not going to allow that. Speed is a strategy."

Lisa trusted me. For the next two-and-a-half months ... we talked, and we waited.

All out warfare


I carefully craft my Addressee List of fourteen high-level decision-makers -- both inside and outside of the insurance company. On Sunday nights, I fax and email the appeal document to all of them.

After I send the appeal -- we do sit around waiting helplessly for the insurance company to have their way with us. No! At 10:00 a.m. on Monday, we begin the Telephone Attack. This is not like calling customer service. I have dug up phone numbers for CEOs, vice presidents, and chief medical officers. I tell my helpee who to call, what to say, what not to say. They report back to me, and I tell them what to say next. The purpose of all this is to keep the pressure on, keep control, and push the appeal through as fast as possible.

These battles are not about clinical appropriateness, and they are not about money. They are about control. An insurance company will fight me tooth and nail to deny a treatment with a mountain of scientific evidence to support it -- which would cost a fraction of the totally unproven treatment which they routinely pay for. It's about control.

My 40-page blockbuster document wrests back control for a few days; the Telephone Attack keeps that control going -- just until they decide to pay for it.

The appeal on their desks first-thing Monday morning. It needs to be approved and wrapped up by Friday. No weekend, no break in the action.

The longer an insurer has to chew on a case, the more ways they will find to deny it.

Speed is a strategy.

Victory is ours

I had Lisa working the phone constantly for two days -- with me coaching, sending additional frosty emails where needed. Strategizing, digging up more phone numbers, calling again.

The surgery was approved at 4:00 p.m. on Tuesday.

This is the story a sweet girl and a lion-of-courage mom who fought against all odds for nine years. The story became mine for two months, we won a great victory, and we shared a moment of pure joy.

It does not get any better than this.

Peaceful Insurance Warrior-ing,

Laurie Todd
health insurance help

P.S. Five thrilling stories have gone by since I wrote my last newsletter; I don't have time to write about them all. Most of the exciting play-by-play happens on my Facebook page: "Laurie Johnson Todd." Come over and join the action!
__________________
"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
Donate www.arthropatient.org/about/donate