The Insurance Intelligencer
12/2/07
The Peer Review
What is the “peer review,” and how can we turn it to our advantage?
Let me take this opportunity to explain—one more time—that the health insurer’s assertions and objections are all smoke and mirrors. Following is a quick refresher course, just to get you in the correct analytical state of mind:
1. What does “experimental” mean?
Nothing. Whatever your health insurer says it means. There is no agreed-upon definition for “experimental.” No matter how I explain this, folks still try to make sense out of these pronouncements by the insurance company. They say, “It must mean ‘not FDA-approved,' right?” Wrong. Health insurers deny FDA-approved treatments every day of the week, and they approve treatments that are not FDA-approved every day of the week. But only if we submit a powerful written appeal to the right decision-makers.
2. If my out-of-network benefit is 80%, I have to pay the other 20%, right?
Wrong. If you write a strong enough appeal, tell all of the things they did wrong in your treatment, quote all the incorrect and embarrassingly untrue things the in-network doctors said, and list two dozen times they have paid for this before, they will be eager to pay the in-network rate, with no patient responsibility. Every item in your benefits booklet is negotiable, except the lifetime maximum.
Onward to the peer review ...
Let’s say that you request a treatment/surgery/medication, and your insurer denies the treatment, stating that it is “experimental, out-of-network, not medically necessary.” At some point in the entire appeals process – could be after the first appeal, could be later – your case may be sent for a “peer review.”
I’ve put you in the appropriately suspicious state of mind, yes? What exactly is this peer review? Many never ask this question. The insurer comes back to them, saying, “The peer reviewer has denied the treatment.” Cast in stone, right? A doctor who is expert and informed about this treatment has said “no,” right?
NOT NECESSARILY. Just start digging, and you may be able to show, once more, that the Health Insurance Emperor Has No Clothes.
One of my brilliant helpees was involved in requesting a very cutting-edge, state of the art radiological treatment for liver metastases. The radiation oncologist who administers this treatment has a twenty-page resume, and a list of published papers as long as your arm.
The case manager says, “The case is going to the peer-to-peer review.”
My helpee managed to weasel the name of the reviewer out of his case manager. Guess who this “peer” was ... a family practice doctor with no special training in oncology, radiology or liver tumors who works for the insurance company. He denied the treatment within one day ... do you think that was long enough for him to study up on the latest treatments for liver metastases?
Dr. Hired Gun’s job is, I suspect, similar to the job of the doctor who is employed by the auto insurer. You know, the one who finds all the ways in which you are not injured.
Once we figure this out, how do we turn it to our advantage?
Simple. Make it a point in your written appeal. Find out who the “peer” is. Make a few statements about the qualifications of your expert-of-choice, and a few more statements about the complexity of the treatment. Mention the three hundred peer-reviewed studies by your doctor-of-choice. Then say, as naively as possible, “Dr. Expert is a surgical oncologist with thirty years experience doing this incredibly complex procedure. I was surprised to learn that Dr. Hired Gun is an OB/GYN, two years out of medical school, who is employed by Acme Insurance.” The assumption being ... your peer was not a peer, and his review holds no water.
Now THAT will be very embarrassing to Acme Insurance, when they see it in print.
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Philosophy Corner
This is my last newsletter of the year; it is time to wax philosophical.
In December 2005, I was sitting around listlessly in my Pillsbury Doughboy pajamas at my friends’ home in Washington, D.C., watching HD TV all day. I had just been sprung out of the hospital after undergoing the Mother of All Surgeries and spending forty days of suffering in the hospital – relieved only by several near-death experiences. I did not know if I would ever have the strength to pour my own glass of juice, and I didn’t have the strength to care.
December 2006. I had by now won two dozen appeals for others, written a book, found a cancer foundation to fund the project.
December 2007. This year, I published the book myself, sold two thousand of them, helped win another dozen appeals, and started the speaking career.
December 2008? I would like to speak at many conferences, sell many boxes of books, and affect how health insurers decide about care. Publish a second book – how about a do-it-yourself appeal workbook, with jaw-dropping helpee success stories woven in? I think big ... who would have predicted what I have done since I was told in March 2005 that I had months to live, and that there was no treatment for my disease.
Perhaps the most important work that I have done during the last three years is to grow in compassion. Sometimes painfully, but always to the good. And to use the words “good” and “bad” much less, choosing instead “desirable” or “undesirable.” Cancer? Undesirable. Becoming a published author? Desirable. Both part and parcel of the ten thousand joys and sorrows that comprise a full life.
Thank you to my readers, friends, and helpees for being brilliant and compassionate participants these past three years ... and for many years to come.
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Need an inspiring gift? One size fits all? How about the book “Fight Your Health Insurer and Win”? Let’s hire me to speak at conferences,get these books to those who need them, and make room in my storage unit for Book Number Two!
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