Reposted for MGS32, two different posts (now deleted) that refer to “The Insurance Warrior.”
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Hi All,
I recently exchanged a few emails with the "Insurance Warrior" (Laurie Todd) and I wanted to post her responses, in case the answers can help anyone else. I'll post both my question and her response below:
My Question -- I work for a private company, which I've been told is self insured and has more of a health insurance "administrator". (I'm not sure of this, but it's something I need to find out). If this is the case, do you know if this will drastically change the plan of attack I take in making my appeal?
"Insurance Warrior's" Response -- Yes, the fact that the company is self-funded makes ALL the difference in how you approach your appeal.
I've done a few self-funded ones, and I have written an article about them. I will also send this to you when I get home.
With a regular insurance plan, the insurance company gets to decide if you get your treatment. When they deny your treatment, you intimidate the insurance company until they pay. The insurance company is subject to state insurance law, and the Insurance Commissioner can be of help, or take your complaint.
In a "self-funded" plan, your employer gets to decide whether you get your treatment/surgery. The money to pay for your surgery comes directly out of the employer's checking account, so they get to decide. In this arrangement, there is no insurance company. All of a sudden, the insurer (Blue Cross, Regence ... no matter who they are) magically turns from an insurance company to a "third party administrator." Your employer is not considered by law to be an insurer, and your insurer is not an insurer.
So ... in the self-funded plan, the insurer and employer are not subject to insurance law, and the Insurance Comissioner cannot help you.
If your appeal gets denied enough times (depends on the plan, usually three or four), the only entity that you can appeal to is the FEDERAL GOVERNMENT (Dept. of Labor). Good luck with THAT! The appeal time with the D.O.L. is six months. Forget it ... you must write an appeal strong enough to nail both the insurer and the employer before you get to that point.
One of the gnarly things with self-funded plans is that the "insurer (third party administrator)" and the employer may hide behind each other. If you talk to the insurer, they say, "We don't have any power to approve this." If you talk to the employer, they say, "We just go by what the Medical Director of the insurance company decides."
Some of the smaller companies who use this set-up totally don't play by any kind of rules, because there is absolutely no regulation of their "insurance" activities. I remember one ADR case where the employer said, "Your husband is a high-level manager here. He already has more benefits than most other employees. If we GIVE you this surgery (as though it were a gift of some sort), other employees will be jealous."
OUTRAGEOUS. If there is any law against it, it is probably a labor law, or some kind of federal statute. If that were me, I would have dug until I found it ... and totally rubbed their noses in it. This person gave up at that point, because she was afraid of further antagonizing the employer.
I fought one of these in person with a local couple. The employer was Boeing, and the "third party" was Regence ... it doesn't get any bigger than that. I had to aim directly at the head of the Medical Director of Regence, and directly at Boeing. It was an in-person hearing. Six Boeing vice presidents, two Medical Directors of Regence, and one corporate attorney. I wrote a speech for the patient's wife, and a speech for me. It was extraordinarily tricky, extrarodinarily difficult, scary as anything. We wiped the floor with them, and they decided to pay within twenty-four hours.
It was after that case that I decided not to get that involved with future appeals.
You need to request your surgery, get denied, and find out where the resistance is coming from. Then, you need to ditch all fear of insurance companies, and all fear of employers. You must intimidate both parties sufficiently to get the job done (make them pay). You must be so intimidating, and so excruciatingly polite, that they don't even THINK about retaliating.
These self-funded plans are horrible news for employees who get sick or need expensive healthcare. Not only do you lose protection of insurance law and the insurance commissioner, but you often have to fight your employer when your are really sick, and most afraid of losing your job. Worst aspect of self-funded plans? The company sets aside x-number of dollars each year to pay for medical treatments. If you come down with cancer towards the end of the year (or fiscal year), they will be just plain out of money, and you just plain won't get any treatment.
Why do companies go for the self-funded plans? They didn't work back in the 1970's, and they don't work now. Companies go for them because they are advertised as "money savers" by the insurance companies. The company gets to save money because the premiums are less than for traditional insurance, and the company gets to control the purse-strings. Further, the insurance companies aggressively push these plans, because a self-funded plan instantly frees them from all regulation.
Find out how the two sides work together at your company. Who is calling the shots, who is standing in your way? Then, put on your velvet gloves, and wield your mighty sledgehammer of facts with the precision of a scalpel.
Feel free to share this verbiage on the ADR website ... I like to help the greatest number of people. Just tell 'em where it came from.
Laurie Todd
The Insurance Warrior
Hi All,
One more email exchange I had with the Insurance Warrior that I wanted to share...
My Question: My question is whether I should hold off on having my doctor's secretary send in a pre-determination letter for my insurance until the ProDisc-C has been FDA approved. A little background: My neurosurgeon told me last week that he had received word that, as of the 1st of the year, he would be able to use the ProDisc-C at two levels off trial. On October 25th, Synthes received the Approvable letter from the FDA for the ProDisc-C, but they have not yet received FDA approval. I spoke to the director of reimbursement at Synthes today, who told me they expect to get FDA approval very soon, but he could not give me an exact date. I assume that my doctor must have been at some conference where this announcement was made that Synthes expects approval by the 1st of the year. So, the director of reimbursement told me I was crazy to submit for insurance approval before FDA approval was announced. Of course, I am anxious to get this process started so that I can hopefully get surgery soon and start feeling better. But, I don't want to hurt my chances by applying prematurely. Any advice/suggestions you have would be great!
"Insurance Warrior's" Response - These "Directors of Reimbursement" ... what do they do? They pay them good money, I presume.
The first of the year is not that far away. However ...
You've read the book by now, yes? What does "experimental" mean? THERE IS NO DEFINITION OF IT. IT MEANS THAT THEY DON'T WANT TO PAY.
They (employer/insurer) don't care if the treatment is good for you or not, is proven or not, is FDA-approved or not. Why doesn't this "Director of Reimbursement" know this?
Insurance companies deny treatments that are FDA-approved every day of the week. They call treatments "experimental" that they have paid for hundreds of times, that they just paid for last week.
Furthermore, when they receive our blockbuster appeals, they paid for treatments that are NOT FDA-approved, that are only offered in other countries, that they have NEVER paid for before. Why? BECAUSE WE INTIMIDATE THEM INTO IT.
By all means wait a month for FDA approval if you want to. However, waiting for such a thing demonstrates that you haven't totally wrapped your mind around this denial of care thing and how it really works.
Just know that an insurance company has NO CRITERIA WHATSOEVER for deeming treatments "experimental" or "not medically necessary." They don't know, they don't care. That's why all of these appeals that detail your terrible quality of life, explain why the treatment will help you, etc. will fail. BECAUSE THEY DON'T CARE ABOUT ANY OF THAT.
It is simply their job not to pay, and your job to make them pay.
You make them pay by preparing a twenty-plus page appeal document. Don't give your whole medical history ... they already know that. Only tell the things that the in-network doctors did wrong. List a dozen different cases (name names, give dates and surgeons) where they paid before. Prove that the treatment is tried-and-true, with excellent results. Attach peer-reviewed articles to meet all objections. Omit all feeling words, sound like the most polished attorney. Make certain that your appeal document gets to the right decision-makers, with copies to important people who will check up on your addressee.
This is all in the book, I've restated it in the Ten Steps. Do exactly what I say, and they will pay.
Share this with your friends on the ADR site, and please remember that -- for both you and the insurer -- this is all one high stakes chess game, one big bluff.
Thank you for letting me rant a bit. They should be paying me instead of all these Reimbursement Specialists. I have won twenty-eight of these, and lost zero. They, from what I have been told, get about a 50% approval rate. I seem to be the only one who understands that this whole denial of care thing is all smoke and mirrors. The insurer is not waiting to be convinced. They are waiting to see if you are clever enough to call their bluff.
Laurie
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