The Insurance Intelligencer 6/15/08
It's YOUR Appeal
Last week I received an email from Jean. She had read my book, and she had a question:
"My husband needs Erbitux. The appeal has been denied. Our next recourse is the Department of Managed Care. Any tips for us?"
I already knew from this message that Jean didn't get it. However, I asked a few questions in order to get Jean to realize that she hadn't gotten it.
1. Why is it that most insurers do not want to pay for Erbitux?
Jean's answer: The money?
Jean hasn't done her research. She doesn't grasp yet that, if appeals are all about money, then we have to know exactly how much everything costs. How much does our requested treatment cost? What treatment would Acme Insurance rather offer you, and how much would THAT cost?
Erbitux (Cetuximab) is the most expensive prescription drug on the planet. A monthly dose costs at least $16,000. Erbitux is a perfect example of an exciting new cancer treatment. The only thing not so exciting is that all of these new cancer treatments will be scary-expensive, and your insurer will not want to pay for them.
You need to know what you are asking from your insurer, money-wise, before you even consider writing an appeal.
2. Who wrote the appeal that failed? What was in it?
Jean's answer: My doctor wrote the appeal.
As my loyal fans and readers know ... "My doctor wrote the appeal" is not an answer. If your doctor is contracted with the insurance company, he is not ideally positioned to mount a powerful appeal for you. If your doctor is not contracted with the insurance company, he has no say with them whatsoever.
Most doctor-written appeals are one- or two-page form letters, which say, "The patient really needs this treatment."
Is that good enough for you?
If you didn't know better at the time, and the doctor did write your losing appeal ... GET A COPY OF IT. Before you can write your own winning appeal, you need to know what didn't work.
3. How do you know that your only recourse is the Department of Managed Health Care?
Jean's answer: We were told ...
"We were told" is not an answer, unless it is immediately followed by " ... and then I looked it up myself."
People, please. When a treatment is denied, the first thing to do is go to your benefits booklet (or the insurer's website), and study their appeals procedure. This is your roadmap, your pathway to approval, your freeway to success.
It is incomprehensible to me that someone could already have one denial, not have any idea what was in the failed appeal, and not know for themselves what levels of appeal were available to them.
Don't ask ME what appeals are available to you ... that is up to your insurance company. By law, this appeal information must be provided to you. It is part of your job as an Insurance Warrior to know the appeals procedures, and follow them to the letter.
By the way, if you call six people at Acme Insurance about appeals, you will get six different answers. "We were told" is a very dangerous -- often fatal -- condition in which to remain.
My questions to Jean regarding where she stands in the appeals process:Who told you? Do they know what they are talking about? What does it say in your benefits booklet? Usually appeals don't go straight from one denial to a government agency.
Since you are under the impression that you must now rely on the Department of Managed Health Care (a California government agency) ... have you studied all about them, and researched THEIR appeals procedures?
I pointed out to Jean that we do not expect government agencies to win our appeals. We do not expect doctors to win our appeals, we do not expect lawyers to win our appeals. We do not expect insurance brokers to win our appeals, we do not expect politicians to win our appeals. And we certainly do not expect Insurance Commissioners to help with our appeals, much less win them.
Whatever you do, I told Jean, write your own appeal. If you must submit some type of form to the Department of Managed Health Care, make your twenty-page appeal an answer to one of the questions, attach it ... and be sure to copy the right decision-makers. Who should you copy?
- The Medical Director of the insurance company
- Two suitable Vice Presidents of the insurance company
- The Executive Director of the Medical Society of your state
No government agency is ever going to move fast enough to save your life. If you have to funnel your appeal through a government agency, you need to get it back through the doors of the insurance company, through your "carbon copies." If you have written a powerful-enough appeal document, the insurer will approve it before the Department of Managed Health Care ever gets around to looking at it.
Thankfully, we are on our own when it comes to writing and winning our appeals, because nobody will ever do a better job than we will.
Of course, it will be much easier for you than it was for me, because my book explains exactly how it's done:
Fight Your Health Insurer and Win: Secrets of the Insurance Warrior Available exclusively at my website:
www.theinsurancewarrior.com
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Or invite the Insurance Warrior to present a seminar or talk to your group.
Contact:
laurie@theinsurancewarrior.com for the media package.
Happy and peaceful Insurance Warrior-ing!
Laurie Todd
If you haven't watched the YouTube video yet, take a look, and leave a comment!
http://www.youtube.com/watch?v=HE_TuDQIwpw