Hi CindyLou --
In order to offer specific advice on why your appeals have not succeeded, I would have to see the appeals. Remember, the intention of a written appeal is to intimidate, not to prove nor to inform.
Regarding the FDA approval, and what qualifications and caveats there are on it ... we will have to get some enlightenment from someone here who is conversant with it. Let me just say that, in the appeals that I have participated in where the insurer said that some procedure was “not FDA-approved,” we ignored it, listed a lot of similar cases where they had paid, a lot of peer-reviewed articles, letters from in-network doctors, made ourselves sound like scary lawyers, and made them pay anyhow. I acknowledge the insurance company objections, but try not to get too mired down in them.
A word or two about “self-funded” plans. We are seeing more and more of them these days. In a self-funded plan, a “third party” administers your benefits, which are paid out of the employer’s bank account. Why the employers go for this option, I do not know. Perhaps they go into it believing that they will be able to better control costs themselves. Some of the terrible consequences that we have seen with self-funded plans:
1. A few employees come down with cancer, and the employer runs out of money before the end of the fiscal year.
2. Employee comes down with cancer, “third party” doesn’t want to pay, employer doesn’t want to pay. Now, you are locked in mortal combat with an insurance company AND your employer ... all while fighting cancer.
3. With both company H.R. department and shadowy “third party” mixed up in it, it is almost impossible to nail down who the decision-makers are.
There are, however, great benefits in these self-funded plans ... for the insurance company. First, is this third party payor a real insurance company, or just an administrative entity? If the third party is not an insurance company, then, in the legal sense, your health insurance is NOT CONSIDERED TO BE INSURANCE. In other words, you cannot appeal to the Insurance Commissioner in your state for help. The self-funded plan is not subject to state law regarding health insurance. Your only protection is the applicable federal law, which is HIPPA. Guess how long HIPPA allows for a determination to be made if there is a dispute or appeal? 120 days.
However, if the third party is a real insurance company – not just an administrator – they will still be subject to the state’s Insurance Commissioner, and state law.
Now to your question of “the employer never gets around to finalizing the insurance plan, and the ‘third party’ will never give me a copy of it.” Honey, I would put all of that in your appeal. I don’t have time to Google all this today, but I believe that, if you call your state’s Insurance Commissioner, they will be able to tell you that there is plenty of law compelling your insurer to provide/disclose total current info about your plan. If I remember HIPPA correctly, they also require this. Remember, these appeals are meant to intimidate, in the legal sense, and leap over specific objections. If I had nothing else to work with, I would seize on this as the centerpiece of my letter to the employer/insurer.
Not that it really matters, because the new plan will, of course, deny again based on them calling the procedure “investigational.” However, I believe that you might be able to make a compelling case about them not providing current coverage info, not having a signed policy in place, etc.
Torpedos away,
Laurie the I.W.
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