A New Tactic
I have already learned something from helping with an ADR case ... the health insurers have adopted a new tactic in their efforts to deny. Keep an eye out for it.
Bear in mind, I am new to the ADR world. So ... I ask some naive questions. The person that I am helping tells me that she is requesting a "second level" disk. I say, "Wait a minute. They paid for it before. In the cancer world, if they pay for it before, we can generally make them pay for it again."
"I did point that out to them," she replied, "They told me that, when they approved it before, they paid by mistake." BY MISTAKE??? This is a new one on me ... the I.W.'s infallible gut-o-meter told me that what we have here is a brand-new objection.
Three days later, I was called in on a rare cancer case. Person needed surgery, insurer didn't want to pay for it. Medical Director of Acme Insurance calls the expert surgeon's office, asserting that the surgery is experimental. Expert surgeon's P.A. says, "Acme Insurance, United Healthcare, Aetna, Cigna ... all of them have been paying for this for years." Medical Director replies, "Acme Insurance would never pay for this. If we ever paid for it, we paid by mistake. You must have given us the wrong CPT codes." Right. This surgery plus hospital costs about $200,000. They goofed up and paid for it without meaning to.
Picture this. Bean counters at the insurance company sitting around, discussing policy: "These patients are starting to talk to each other. They are presenting us with lists of cases where we have paid before. We need to find some way to counteract this. Let's just say we paid by mistake!" Apparently the memo went out industry-wide.
Here is how I handled it. I wrote a letter for these folks -- in the patient's voice, of course. I quoted every absurd, untrue, insulting thing the Medical Director said to the expert surgeon's office. Dragged the whole stinkin' conversation out of the closet. As a cherry on the sundae, I added a few more instances where they told untruths, sent the patient to a local surgeon with no experience who would surely have killed him, etc.
I had them fax it to everyone from the Medical Director on down, everyone who is anyone at the employer, and so on.
I have shamed and embarrassed customer service people, case managers, and many doctors who told untruths or denied care, but never a Medical Director. My letter (from the patient) should hit the fan tomorrow. The surgery is scheduled for June 4. The usual last-minute cliff-hanger.
If somebody at the insurance company says something to you which is absurd, ridiculous, untrue, or contrary to your benefits booklet ... people, that is your gold nugget. They have just given you the most powerful ammo you could have. You are going to quote them in your letter -- word-for-word.
The whole idea with these appeals is to make yourself sound so dangerous, such a hot potato, that they pay just to get rid of you.
It is really quite strange. Here I am writing all of these letters in the voice of the patient. Or else, patients are using the words from the book. Hopefully it takes a few years before insurance companies start scratching their heads and wondering how all of their insureds suddenly got to be such good writers.
So ... if your insurer says that they paid for this before "by mistake," quote them in your letter. It is a ridiculous thing to say. Also, supply a list with patient names, surgeon's names, and surgery dates where they have paid for this before. Make it personal, not just a list of cases that have been paid. Surely four different surgeons' offices couldn't all have submitted the wrong codes.
I would have fun with it. If somebody told me that over the phone, I would calmly ask, "So ... you're telling me that Acme Insurance has paid by mistake for many surgeries costing in excess of $50,000? MAY I QUOTE YOU ON THAT?"
Go get 'em
Laurie the I.W.
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