View Single Post
  #39  
Old 03-04-2010, 06:25 PM
Harrison's Avatar
Harrison Harrison is offline
Administrator
 
Join Date: Oct 2004
Posts: 7,010
Default Insurance Intelligencer 3/2/10

The Emperor Has No Clothes

A woman in Minnesota sent me a copy of her appeal. She had followed all of the suggestions in my CD. She did the research, performed her due diligence, proved her points.

When I read this appeal, I knew that it wouldn't fly. She sounded too much like an eager student, hoping for an "A." It was earnest, not intimidating.

An illusion of due process

In order to face off against an insurer, and win the battle on their home ground -- we need to bear in mind that the appeals process is not meant to lead to an approval.

Appeal levels, peer reviews, hearings, committees, independent reviews -- none are meant to lead to an approval. If we believe that we will get unbiased consideration at any of these levels, we miss the poiint, we charge up the wrong hill, we are barking up the wrong tree.

Disclaimer: I am not saying that no medical director ever considered a treatment in good faith, based on whether or not it was safe and effective. I've just never seen it happen.

How can I tell that this system of appeals and grievances is a stacked deck? Let me count the ways ...

The telephone game

You are allowed access only to people with no decision-making power -- customer service reps and case managers. This phone interation is not meant to bring you any closer to an approval.

What is the job of a customer service rep? To tell you to wait for a letter. What is the job of a case manager? To tell you to wait for a letter.

First and second level reviews

A treatment is "medically necessary," if the medical director of the insurance company says it is. It is "experimental," if the medical director of the insurance company says it is.

In all of my fifty-seven cases -- the medical director knew nothing about the treatment under review, and he was not qualified to render an opinion on the treatment. The majority of these medical directors are "family practice physicians." It must be slow times in the "family practice" business, since so many of them have resorted to working for insurance companies.

My favorite unqualified medical director had denied reconstructive skull surgery for one of my infant helpees. He was a psychiatrist. We joked, "Hey, I guess they figured head/skull, same geographical location ..." At a certain point, I said to her, "The next time you call that medical director, tell him that these denials are driving us CRAZY, and we need a session!" He knew nothing about skull surgery, nor did he care to learn about it.

I have never seen an insurance company reverse a decision from first- to second-level review. Unless, of course, they received a powerful appeal from the patient in the interim. One medical director will not rule differently than another; they both work for the same insurance company.

Medical policy statements

Med policies are a body of hundreds of official-looking documents. Every insurer has them. They give the scientific reasons why the insurer isn't going to pay for your treatment. No matter what your coverage is, they aren't going to pay for it.

Medical policies were instituted in the 1990s in response to a hue and cry from outraged insured people. They had figured out that insurers could pretty much call any treatment "experimental" or "not medically necessary" -- with little or no justification.

Med policies are supposed to hold insurers to some kind of scientific standard. Guess who writes them? Insurance companies.

If you don't believe that medical policy statements are sham documents -- consider the Tale of the Two Medical Policies.

I decided to find and print all of the medical policy statements that I could find for hyperthermic intraperitoneal chemotherapy (HIPEC) -- the treatment that I had in 2005, and for which I have written many appeals.

The med policy from Blue Cross Blue Shield of Massachusetts started looking familiar. It declared HIPEC to be "medically necessary," and cited twenty-nine medical articles and other sources. I pulled out the Premera Blue Cross medical policy, which deems this treatment to be "experimental." Both med policies used the same twenty-nine articles to prove that HIPEC was both experimental, and not experimental.

These documents are not designed to hold insurers to any standard. They are meant to look official, with the expectation that nobody but me will ever challenge them.

Peer reviews

The peer review is where the same medical director who denied the treatment the first time calls your doctor, and tells them why they aren't going to pay for it. This medical director is a family practice physician. He is not a surgeon, a cancer expert, or any other type of "peer." He is not a peer, and it is not a review.

Independent reviews

People get pretty excited, when they lose a few appeal levels and their case goes to independent review. They say, "It's independent, that's got to be good, right?"

Like med policies, independent reviews came into being because people got fed up with insurers denying whatever they wanted to deny, with no checks and balances. Only problem? There are no checks and balances on independent review orgs.

Independent review organizations are not licensed or regulated. They are not required to employ "medical experts." In many states, they are not held to any standard at all. I delved into an independent review org that was about to rule on one of my cases -- it consisted of a chiropractor in Texas with a post office box.

Independent review orgs are not accessible, and they are not accountable. They could uphold every denial that came their way, and nobody would ever be the wiser.

Word to the wise: If you want to make the most of this illusion of due process, at least put a powerful appeal in front of these review org people. Even if they know nothing, and aren't required to do anything -- that chiropractor in Texas might be impressed enough to reverse your denial.

In order to win our appeals, we need to know our opponent, and stay focused on the big picture. The only due process that we can expect from our insurance companies is the due process that we create ourselves.

Listen to my new audio spot:
http://www.carcinoid.org/insurance/index.shtml

*******

My two books are now available as E-books!
http://www.theinsurancewarrior.com/ebooks.html

More affordable, instant download!
__________________
"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