The Insurance Intelligencer
"You can't appeal it, because we didn't deny it:"
The case of little Oliver
Most of the cases that I write appeals for these days are not denials. I am appealing treatments that have been approved. How can this be?
I am appealing expensive surgeries and treatments that have been approved at the out-of-network rate.
In a PPO plan, you pay more for monthly premiums, co-pays, co-insurances, out-of-pocket expenditures. You pay more for everything. You pay all this so that you can go anywhere you want for treatment, and your insurer will pay 80%. That's how a PPO works, right?
Wrong. Joke's on you. You just got sucked in by the biggest con game in the history of health insurance. People who blithely go for expensive out-of-network treatments or surgeries just climbed on the slippery slope to the poorhouse.
A PPO approval is the same as a denial
Why am I not seeing so many outright denials these days? Because you can appeal a denial ... and you may win. Insurers don't want to devote resources to dealing with appeals, and they don't want to pay for expensive treatments. How to shut the door firmly, without leaving you any recourse?
Thus was born the PPO. Make the insured people believe that "they can go anywhere," and "we will pay 80%." Make them pay more for everything -- higher monthly premiums, higher co-pays, higher co-insurances. When expensive out-of-network treatment or surgery is needed, send a letter that says, "Treatment APPROVED!" Just don't tell them what you are going to pay 80% OF. Keep that a huge secret. Just tell them it's approved.
Make sure that they go into that surgery believing that it's all taken care of. As long as they stay ignorant until after the surgery date, you're home free ... because after the surgery, they're sick, they're weak, the bills are going out. They have lost their leverage, and you won't have to pay for it.
Finally, the doctors -- who have been paid $400 for a $30,000 surgery -- start balance-billing the patients. You can then blame their problems on the "greedy doctors."
Brilliant.
Little Oliver needs his head fixed
Which brings me to the case of little Oliver in California. I have written eight appeals for children with craniosynostosis. These children are born with one or more of the sutures of the skull prematurely fused. The minute these sutures fuse, the head -- and brain -- is prevented from growing in the right directions, and it starts growing in the wrong directions. This results in an unusual appearance, and scary possibilities for the brain if not correctly treated.
The surgery to fix these children's little heads is a mixture of art and science. Insurance companies would just as soon have you take your child to the local in-network plastic surgeon who specializes in breast enhancements and liposuction, rather than a pediatric craniofacial surgeon who specializes in this condition. Hey, he's an M.D. That's good enough for the insurance company.
Think you will never need out-of-network treatment? Do you believe that every surgeon with an M.D. is created equal, and every treatment that you could possibly need from cradle to grave is available locally, and in the insurance network? Say that to me again, when you are diagnosed with a difficult brain tumor, and none of the local talent have the skills to remove it.
Oliver's insurance company -- Anthem Blue Cross of California -- has approved his surgery with out-of-network craniofacial surgeon Dr. Fearon in Texas. Only problem? They have approved it at the "out-of-network" rate.
Insurers will fight to the death any attempt to get them to reveal how much they will be paying. However, around the time that Oliver's case came up, a Blue Cross and Blue Shield company revealed how much they were planning to pay Dr. Fearon for this surgery. The billed charge for Dr. Fearon and his assisting surgeon combined is about $28,000. Blue Cross and Blue Shield approved the surgery as out-of-network, and planned to pay $1,000 for it. The patient would be responsible for the $27,000 that they didn't pay. This is really how little they pay.
Sound lke good coverage to you? Let's say you have a $28,000 car, and full coverage with your auto insurer. The car is totalled, and the insurer gives you a check for $1,000. Are you outraged? Are you hollering and screaming at everyone who will listen? Why are people not hollering and screaming about this cruel scam that is the PPO?
How to appeal the approval
If the insurer says that I can't appeal, that is not going to stop me. It's easy -- I just don't call it an "appeal." I call it a "request for reconsideration."
It's all about the words. Treatments are denied with words. Denials are overturned by taking the insurer's words, and turning them to our advantage.
As I look back on it, the plain old denials were a whole lot easier to fight than these deceptive approvals. I have always had to get up very early in the morning to get ahead of insurance company words. In 2011, I have to get up in the middle of the night.
That's exceedingly OK. I will rest when the case is won, the expert surgeon is paid fairly for his work, and the child is home sleeping in his own bed -- with a perfect, round head.
After a few days in the trenches, we won Oliver's "Urgent Expedited Request for Reconsideration." He had his surgery last Wednesday, and is happily playing at home in California with his friends, and his favorite goats. The big challenge for his parents is to keep him from running around and being too rambunctious, as they are keen to protect his perfect head.
Peaceful Insurance Warrior-ing,
Laurie Todd
health insurance help