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Old 06-03-2012, 02:42 PM
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Harrison Harrison is offline
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Good job, Laurie! Helpful analysis too - especially on the "danger of medical privacy."
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The Insurance Intelligencer 6/4/12

The bigger they are, the quicker they fall

On Wednesday I received a call from Michael and Carrie in Vermont. We have been friends since her surgery with Dr. Sugarbaker in 2009. Her second surgery with Dr. Sugarbaker was scheduled for next Tuesday.

Their insurance company -- MVP, a subsidiary of Cigna -- had been stringing them along for months. Now, one week before the surgery, it was clear that they weren't planning to pay. Cigna had paid for Carrie's first surgery with Dr. Sugarbaker in 2009. It's just that Cigna (masquerading as "MVP") didn't want to pay for it again.

It was clear that I would have to stay up all night and write the appeal on Wednesday night. I would fax and email the appeal to fourteen movers and shakers by 5:00 a.m. Pacific time on Thursday. We would then have to spend all day Thursday on the phone with the appropriate executives.

Michael is insured under a self-funded plan. In a self-funded plan, it is the employer who pays for your medical treatments. Therefore, your employer gets to decide whether or not you will be allowed to have a medical treatment.

Our task was to make Michael's employer reverse their denial within two days. Guess who the employer is? IBM.

In this story, we will see that private medical information is the most powerful weapon that we have to fight insurance denials -- and that this information is the most precious gift that we can give ...

The gift of precedent

By 5:30 p.m., I was knee-deep in Carrie's appeal. All of a sudden, it dawned on me -- I had won a case for an IBM employee for this treatment before.

Back in 2007, Al from New York contacted me. His partner Dan had appendix cancer, and he wanted to Dr. Sardi in Baltimore for surgery. Healthnet had denied it. Same employer as my current case, same disease, different surgeon, different insurance company. All in all, an excellent case of precedent. However, it gets better ...

I called Al. Thankfully, he was home. I told him that my current helpee, Carrie, was going back for a second surgery with Dr. Sugarbaker, and MVP was denying it. I said, "Wait just a doggone minute. Dan had a second surgery last year -- who was the insurance company on that one?" Al replied, "MVP."

But it gets even better. Dan's recurrence was in an unusual place: the lung. His second surgery was with a famous thoracic surgeon in Boston -- Dr. David Sugarbaker, Dr. Paul Sugarbaker's brother.

I couldn't make this stuff up. This is truly the world's most elegant case of precedent.

Slam dunk


Of course, even with Dan's case, 153 other cases of prececent, and a 49-page document -- no employer or insurer ever has to pay for anything. I prepared Michael for the usual full-court press for Thursday -- Michael phoning executives at MVP and Cigna, me coaching behind the scenes, more calls, more strategizing.

Four hours later, IBM and Cigna/MVP decided to pay.

Medical privacy

Over the past forty years, private insurers have waged an all-out propaganda war on the American public. They have been very successful at molding our opinions. Most people believe the following myths:
• Insurance companies will cover our expenses when we get sick.
• If we have health insurance, we are protected from financial ruin.
• Insurance companies are more qualified to make medical decisions than doctors are.
• The main problem with our healthcare system is lazy unhealthy people with bad habits who choose not to have health insurance.
• The other main problem with our healthcare system is greedy doctors.
All unfair, unfounded, and untrue.

With the guidance of insurance companies, we have come to believe that our private medical information is terribly dangerous. Go on any insurance company website. They will assure you up one side and down the other as to how scrupulous they are about protecting your private medical information. The impression is that evil forces are lurking around, just itching to get their hands on your medical information. But never fear! The insurance company is there to protect you!

Ever wonder why insurers are so in love with medical privacy, and medical privacy laws?

When an insurance company denies a treatment as "experimental," or as "not medically necessary" ... it is very embarrassing for them to see on paper that they have paid for it three dozen times before.

Insurance companies despise precedent. It shows that the entire denial/review/appeals process is based on deception.

*****

I have spent seven years building my list of precedent for cytoreductive surgery and HIPEC. I now have 153 cases where insurers have fully funded this treatment -- most of them with out-of-network, out-of-area medical providers. First name, last name, diagnosis, date of surgery, name of surgeon, name of insurance company.

I love my list of precedent for CRS/HIPEC. I include all 153 cases with every appeal for this issue -- rearranged depending upon which disease the person has, and who is the insurance company. Whenever I retool and use my list, I think of the precious helpees and friends who have come before. Their cases go on to help others. My precedent list is a powerful tribute to them.

Insurance companies despise precedent. They have gone to great lengths over the past forty years to persuade us that we must never reveal it. I say: Learn to love your private medical information. It is the most powerful tool you have, in order to help others to access the legitimate, clinically-appropriate treatments which insurers have paid for so many times before.

I will put my medical info out on the Internet. I will hand it out on the street corner, if it will help one other patient.

It pains me to see an entire country succumb to propaganda. Propaganda so pervasive, so expertly deployed, so accepted, so believed. Proganda so powerful that it disempowers us in the very moment when we need every bit of our free will and critical thinking in order to save our own lives.

Remember Al and Dan, my helpees from 2007? Dan died last year. I knew that I could call Al and talk about precedent because we are friends -- and because of his generous heart.

This is not about private medical information. This is about truth. This is about justice. This is about overcoming fear, and about reaching out a hand to help.

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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