ADRSupport Community  

Go Back   ADRSupport Community > General Discussion > Insurance Hell

Insurance Hell All insurance-related matters are here: Medicare, worker's compensation, appeals, denials, insights, wins, losses. PRICING is here too. Note: This forum has posts from 2006 forward. Older ones are in the Big File.


Reply
 
Thread Tools
  #21  
Old 05-26-2007, 01:09 PM
CindyLou's Avatar
CindyLou CindyLou is offline
Senior Member
 
Join Date: Mar 2007
Posts: 627
Default

Oh, almost forgot. Laurie I.W., I sent you an email asking about your fee. Just wanted to make sure you saw it. Thanks.
__________________
CindyLou
bicycle accident 6/19/01
2 compression fractures, T12, L1;
vertibroplasty @ above levels, 9/15/01
4/06 hip labral tear repair
4/07 Lumbar ProDisc replacement by Dr. B., 3 levels; L3-6
7/2/08 ALIF of L6-S1
7/30/08 Removed bone cement.
8/7/08 Diagnosed with pulmonary embolism, double pneumonia, collapsed left lung, pleurisy, pleural effusion.
3/10/09 right SI Joint Fusion; seeing light at end of tunnel, for first time in 8 years!!
Reply With Quote
  #22  
Old 05-26-2007, 07:16 PM
Terry's Avatar
Terry Terry is offline
Senior Member
 
Join Date: Oct 2006
Posts: 1,210
Default

I agree, GET MAD!

People who turn that inward just get depressed and the profit-mongers win. They do not expect most people to fight. Most back down as they think the company has bigger and better lawyers.

Editorials work nice also as long as you stick to the facts to avoid slander. Don't give them any amunition and use theirs against them.

Make yourself a thorn in their sides and they will be throwing money at you.

Go with God and a Club!

Terry Newton
__________________
1980 ruptured L4-L5
1988 ruptured SI-L5
1990 ruptured C5-C6
1994 ruptured C6-C7
1995 Hemi-Laminectomy C5-C6, C6-C7 Mayo Clinic
Bicycle Accident 2004
MRI, EMG, Facet Injections, Epidural Blocks, Lumbar Discogram.
Stenum Hospital Surgery November 4, 2006
Prestige Disc C5-C6, C6-C7
Maverick Disc S1-L5, L4-L5
Reply With Quote
  #23  
Old 05-31-2007, 10:53 AM
Teresa Teresa is offline
Junior Member
 
Join Date: May 2007
Posts: 12
Default

Self Funded Plans, regardless of whether they are administered from a Commercial Carrier or a Third Party Adminstrator (TPA), are regulated under a Federal Bill called ERISA. ERISA over rides any state law unless the state law provides for greater benefits to the patient. ERISA provides very specific appeals processes as well as language regarding the Summary Plan Document (SPD). Please see this brief article below taken from the DOL Website. When researching ERISA information, please note that you have to be careful to search for the appropriate and applicable parts, as ERISA also covers many other benefits, such as retirement accounts, etc. I hope those of you that are covered by a Self Insured Plan find this helpful.
U.S. Department of Labor
Workers’ Right To Health Plan Information

Printer Friendly Version

The Employee Retirement Income Security Act (ERISA) governs approximately 2.5 million health benefit plans sponsored by private sector employers nationwide. These plans provide a wide range of medical, surgical, hospital and other health care benefits to some 134 million Americans.

Under ERISA, workers and their families are entitled to receive a summary plan description (SPD). The SPD is the primary document that gives information about the plan, what benefits are available under the plan, the rights of participant and beneficiaries under the plan, and how the plan works.

Among other information, the SPD of health plans must describe:

Cost-sharing provisions, including premiums, deductibles, coinsurance and copayment amounts for which the participant or beneficiary will be responsible

Annual or lifetime caps or other limits on benefits under the plan

The extent to which preventive services are covered under the plan

Whether, and under what circumstances, existing and new drugs are covered under the plan

Whether, and under what circumstances, coverage is provided for medical tests, devices and procedures

Provisions governing the use of network providers, the composition of provider networks and whether, and under what circumstances, coverage is provided for out-of-network services

Conditions or limits on the selection of primary care providers or providers of specialty medical care

Conditions or limits applicable to obtaining emergency medical care

Provisions requiring preauthorizations or utilization review as a condition to obtaining a benefit or service under the plan

The SPD must also explain how plan benefits may be obtained and the process for appealing denied benefits.

ERISA also requires that SPDs be updated periodically. Furthermore, ERISA requires disclosure of any material reduction in covered services or benefits to participants and beneficiaries generally within 60 days of the adoption of the change through either a revised SPD or a summary of material modification (SMM). Material changes that do not result in a reduction in covered services or benefits must be disclosed through an SMM or revised SPD not later than 210 days after the end of the plan year in which the change was adopted.

The department’s claims procedure regulation describes your right to get an answer from your health plan regarding your health benefit claim. The regulation protects you – providing for a timely response by describing the time frames for a decision, providing for a fair process by describing the standards for a decision, and providing for meaningful disclosure by describing the notice and disclosure that you are entitled to receive from your plan. Look to the SPD for information on your health plan’s claims procedure.

This fact sheet has been developed by the U.S. Department of Labor, Employee Benefits Security Administration, Washington, DC 20210. It will be made available in alternate formats upon request: Voice phone: 202.693.8664; TTY: 1.202.501.3911. In addition, the information in this fact sheet constitutes a small entity compliance guide for purposes of the Small Business Regulatory Enforcement Fairness Act of 1996.

U.S. Department of Labor
Frances Perkins Building
200 Constitution Avenue, NW
Washington, DC 20210
1.866.444.3272
TTY: 1.877.889.5627
Contact Us
__________________
Teresa
"I can be changed by what hapens to me. But, I refuse to be reduced by it." Author: Maya Angelou
Injury July 2004 neck and low back
Conservative Evaluation and Treatment to include PT, ESIs, etc for lumbar and cervical.
January 2005 C5-6 a
Reply With Quote
  #24  
Old 05-31-2007, 11:03 AM
Teresa Teresa is offline
Junior Member
 
Join Date: May 2007
Posts: 12
Default

Some more good information on ERISA Governed Plans:

U.S. Department of Labor

Filing A Claim For Your Health Or Disability Benefits

Printer Friendly Version • PDF Version

Introduction

If you participate in a health plan or a plan that provides disability benefits, you will want to know how to file a claim for your benefits. The steps outlined below describe some of your plan’s obligations and briefly explain the procedures and timelines for filing a health or disability benefits claim.

Before you file, however, be aware of the Employee Income Retirement Security Act of 1974 (ERISA), a law that protects your health and disability benefits and sets standards for those who administer your plan. Among other things, the law and rules issued by the Department of Labor include requirements for the processing of benefit claims, the timeline for a decision when you file a claim, and your rights when a claim is denied.

You should know that ERISA does not cover some employee benefit plans (such as those sponsored by government entities and most churches). If, however, you are one of the millions of participants and beneficiaries who depend on health or disability benefits from a private-sector employment-based plan, take a few minutes and read on to learn more.

Reviewing The Summary Plan Description

A key document related to your plan is the summary plan description (SPD). The SPD provides a detailed overview of the plan – how it works, what benefits it provides, and how to file a claim for benefits. It also describes your rights as well as your responsibilities under ERISA and your plan. For some single-employer collectively bargained plans, you should also check the collective bargaining agreement’s claim filing, grievance, and appeal procedures as they may apply to claims for health and disability benefits.

Before you apply for health or disability benefits, review the SPD to make sure you meet the plan’s requirements and understand the procedures for filing a claim. Sometimes claims procedures are contained in a separate booklet that is handed out with your SPD. If you do not have a copy of your plan’s SPD or claims procedures, make a written request for one or both to your plan’s administrator. Your plan administrator is required to provide you with a copy.

Filing A Claim

An important first step is to check your SPD to make sure you meet your plan’s requirements to receive benefits. Your plan might say, for example, that a waiting period must pass before you can enroll and receive benefits or that a dependent is not covered after a certain age. Also, be aware of what your plan requires to file a claim. The SPD or claims procedure booklet must including information on where to file, what to file, and whom to contact if you have questions about your plan, such as the process for providing a required pre-approval for health benefits. Plans cannot charge any filing fees or costs for filing claims and appeals.

If, for any reason, that information is not in the SPD or claims procedure booklet, write your plan administrator, your employer’s human resource department (or the office that normally handles claims), or your employer to notify them that you have a claim. Keep a copy of the letter for your records. You may also want to send the letter by certified mail, return receipt requested, so you will have a record that the letter was received and by whom.

If it is not you, but an authorized representative who is filing the claim, that person should refer to the SPD and follow your plan’s claims procedure. Your plan may require you to complete a form to name the representative. If it is an emergency situation, the treating physician can automatically become your authorized representative without you having to complete a form

When a claim is filed, be sure to keep a copy for your records.

Types Of Claims

All health and disability benefit claims must be decided within a specific time limit, depending on the type of claim filed.

Group health claims are divided into three types: urgent care, pre-service and post-service claims, with the type of claim determining how quickly a decision must be made. The plan must decide what type of claim it is except when a physician determines that the urgent care is needed.

Urgent care claims are a special kind of pre-service claim that requires a quicker decision because your health would be threatened if the plan took the normal time permitted to decide a pre-service claim. If a physician with knowledge of your medical condition tells the plan that a pre-service claim is urgent, the plan must treat it as an urgent care claim.

Pre-service claims are requests for approval that the plan requires you to obtain before you get medical care, such as preauthorization or a decision on whether a treatment or procedure is medically necessary.

Post-service claims are all other claims for benefits under your group health plan, including claims after medical services have been provided, such as requests for reimbursement or payment of the costs of the services provided. Most claims for group health benefits are post-service claims.

Disability claims are requests for benefits where the plan must make a determination of disability to decide the claim.

Waiting For A Decision On Your Claim

As noted, ERISA sets specific periods of time for plans to evaluate your claim and inform you of the decision. The time limits are counted in calendar days, so weekends and holidays are included. These limits do not govern when the benefits must be paid or provided. If you are entitled to benefits, check your SPD for how and when benefits are paid. Plans are required to pay or provide benefits within a reasonable time after a claim is approved.

Urgent care claims must be decided as soon as possible, taking into account the medical needs of the patient, but no later than 72 hours after the plan receives the claim. The plan must tell you within 24 hours if more information is needed; you will have no less than 48 hours to respond. Then the plan must decide the claim within 48 hours after the missing information is supplied or the time to supply it has elapsed. The plan cannot extend the time to make the initial decision without your consent. The plan must give you notice that your claim has been granted or denied before the end of the time allotted for the decision. The plan can notify you orally of the benefit determination so long as a written notification is furnished to you no later than three days after the oral notification.

Pre-service claims must be decided within a reasonable period of time appropriate to the medical circumstances, but no later than 15 days after the plan has received the claim. The plan may extend the time period up to an additional 15 days if, for reasons beyond the plan’s control, the decision cannot be made within the first 15 days. The plan administrator must notify you prior to the expiration of the first 15-day period, explaining the reason for the delay, requesting any additional information, and advising you when the plan expects to make the decision. If more information is requested, you have at least 45 days to supply it. The plan then must decide the claim no later than 15 days after you supply the additional information or after the period of time allowed to supply it ends, whichever comes first. If the plan wants more time, the plan needs your consent. The plan must give you written notice that your claim has been granted or denied before the end of the time allotted for the decision.

Post-service health claims must be decided within a reasonable period of time, but not later than 30 days after the plan has received the claim. If, because of reasons beyond the plan’s control, more time is needed to review your request, the plan may extend the time period up to an additional 15 days. However, the plan administrator has to let you know before the end of the first 30-day period, explaining the reason for the delay, requesting any additional information needed, and advising you when a final decision is expected. If more information is requested, you have at least 45 days to supply it. The claim then must be decided no later than 15 days after you supply the additional information or the period of time given by the plan to do so ends, whichever comes first. The plan needs your consent if it wants more time after its first extension. The plan must give you notice that your claim has been denied in whole or in part (paying less than 100% of the claim) before the end of the time allotted for the decision.

Disability claims must be decided within a reasonable period of time, but not later than 45 days after the plan has received the claim. If, because of reasons beyond the plan’s control, more time is needed to review your request, the plan can extend the timeframe up to 30 days. The plan must tell you prior to the end of the first 45-day period that additional time is needed, explaining why, any unresolved issues and additional information needed, and when the plan expects to render a final decision. If more information is requested during either extension period, you will have at least 45 days to supply it. The claim then must be decided no later than 30 days after you supply the additional information or the period of time given by the plan to do so ends, whichever comes first. The plan administrator may extend the time period for up to another 30 days as long as it notifies you before the first extension expires. For any additional extensions, the plan needs your consent. The plan must give you notice whether your claim has been denied before the end of the time allotted for the decision.

If your claim is denied, the plan administrator must send you a notice, either in writing or electronically, with a detailed explanation of why your claim was denied and a description of the appeal process. In addition, the plan must include the plan rules, guidelines, protocols, or exclusions (such as medical necessity or experimental treatment) used in the decision or provide you with instructions on how you can request a copy from the plan. The notice may also include a specific request for you to provide the plan with additional information in case you wish to appeal your denial.

Appealing A Denied Claim

Claims are denied for various reasons. Perhaps the services you received are not covered by your plan. Or, perhaps the plan simply needs more information about your claim. Whatever the reason, you have at least 180 days to file an appeal (check your SPD or claims procedure to see if your plan provides a longer period).

Use the information in your claim denial notice in preparing your appeal. You should also be aware that the plan must provide claimants, on request and free of charge, copies of documents, records, and other information relevant to the claim for benefits. The plan also must identify, on your request, any medical or vocational expert whose advice was obtained by the plan. Be sure to include in your appeal all information related to your claim, particularly any additional information or evidence that you want the plan to consider, and get it to the person specified in the denial notice before the end of the 180-day period.

Reviewing An Appeal

On appeal, your claim must be reviewed by someone new who looks at all of the information submitted and consults with qualified medical professionals if a medical judgment is involved. This reviewer cannot be a subordinate of the person who made the initial decision and must give no consideration to that decision.

Plans have specific periods of time within which to review your appeal, depending on the type of claim.

Urgent care claims must be reviewed as soon as possible, taking into account the medical needs of the patient, but not later than 72 hours after the plan receives your request to review a denied claim.

Pre-service claims must be reviewed within a reasonable period of time appropriate to the medical circumstances, but not later than 30 days after the plan receives your request to review a denied claim.

Post-service claims must be reviewed within a reasonable period of time, but not later than 60 days after the plan receives your request to review a denied claim.

If a group health plan needs more time, the plan must get your consent. If you do not agree to more time, the plan must complete the review within the permitted time limit.

Disability claims must be reviewed within a reasonable period of time, but not later than 45 days after the plan receives your request to review a denied claim. If the plan determines special circumstances exist and an extension is needed, the plan may take up to an additional 45 days to decide the appeal. However, before taking the extension, the plan must notify you in writing during the first 45-day period explaining the special circumstances, and the date by which the plan expects to make the decision.

There are two exceptions to these time limits. In general, single-employer collectively bargained plans may use a collectively bargained grievance process for their claims appeal procedure if it has provisions on filing, determination, and review of benefit claims. Multi-employer collectively bargained plans are given special timeframes to allow them to schedule reviews on appeal of post-service claims and disability claims for the regular quarterly meetings of their boards of trustees. If you are a participant in one of those plans and you have questions about your plan’s procedures, you can consult your plan’s SPD or contact the Department of Labor’s Employee Benefits Security Administration (EBSA) at the phone number below.

Plans can require you to go through two levels of review of a denied health or disability claim to finish the plan’s claims process. If two levels of review are required, the maximum time for each review generally is half of the time limit permitted for one review. For example, in the case of a group health plan with one appeal level, as noted above, the review of a pre-service claim must be completed within a reasonable period of time appropriate to the medical circumstances but no later than 30 days after the plan gets your appeal. If the plan requires two appeals, each review must be completed within 15 days for pre-service claims. If your claim on appeal is still denied after the first review, the plan has to allow you a reasonable period of time (but not a full 180 days) to file for the second review.

Once the final decision on your claim is made, the plan must send you a written explanation of the decision. The notice must be in plain language that can be understood by participants in the plan. It must include all the specific reasons for the denial of your claim on appeal, refer you to the plan provisions on which the decision is based, tell you if the plan has any additional voluntary levels of appeal, explain your right to receive documents that are relevant to your benefit claim free of charge, and describe your rights to seek judicial review of the plan’s decision.

If Your Appeal Is Denied

If the plan’s final decision denies your claim, you may want to seek legal advice regarding your rights to bring an action in court to challenge the denial. Normally, you must complete your plan’s claim process before filing an action in court to challenge the denial of a claim for benefits. However, if you believe your plan failed to establish or follow a claims procedure consistent with the Department’s rules described in this booklet, you may want to seek legal advice regarding your right to ask a court to review your benefit claim without waiting for a decision from the plan. You also may want to contact the nearest EBSA office about your rights if you believe the plan failed to follow any of ERISA’s requirements in handling your benefit claim.

Filing a Claim – Summary

Check your plan’s benefits and claims procedure before filing a claim. Read your SPD and contact your plan administrator if you have questions.

Once you claim is filed, the maximum allowable waiting period for a decision varies by the type of claim, ranging from 72 hours to 45 days. However, your plan can extend certain time periods but must notify you before doing so. Usually, you will receive a decision within this timeframe.

If your claim is denied, you must receive a written notice, including specific information about why your claim was denied and how to file an appeal.

You have at least 180 days to request a full and fair review of your denied claim. Use your plan’s appeals procedure and be aware that you may need to gather and submit new evidence or information to help the plan in reviewing the claim.

Reviewing your appeal can take between 72 hours and 60 days depending on the type of claim. The law and the Department’s rules allow a disability plan additional time if the plan’s administrator has notified you beforehand of the need for an extension. For an appeal of a health claim, the plan needs your permission for an extension. The plan must send you a written notice, telling you whether the appeal was granted or denied.

If the appeal is denied, the written notice must tell you the reason it was denied, describe any additional appeal levels or voluntary appeal procedures offered by the plan, and contain a statement regarding your rights to seek judicial review of the plan’s decision.

You may decide to seek legal advice if your claim’s appeal is denied or if the plan failed to establish or follow reasonable claims procedures. If you believe the plan failed to follow ERISA’s requirements, you also may want to contact the nearest EBSA office concerning your rights under ERISA.

Resources

For the EBSA regional office nearest you or a copy of any EBSA publications, call toll free: 1.866.444.EBSA (3272), or visit EBSA’s Web site at: www.dol.gov/ebsa

This publication has been developed by the U.S. Department of Labor, Employee Benefits Security Administration. For a complete list of the agency's publications, call our toll free number at 1.866.444.EBSA (3272). This material will be made available in alternate format upon request: Voice phone: 202.693.8664, TTY: 202.501.3911.

This booklet constitutes a small entity compliance guide for purposes of the Small Business Regulatory Enforcement Act of 1996.

U.S. Department of Labor
Frances Perkins Building
200 Constitution Avenue, NW
Washington, DC 20210
1.866.444.3272
TTY: 1.877.889.5627
Contact Us
__________________
Teresa
"I can be changed by what hapens to me. But, I refuse to be reduced by it." Author: Maya Angelou
Injury July 2004 neck and low back
Conservative Evaluation and Treatment to include PT, ESIs, etc for lumbar and cervical.
January 2005 C5-6 a
Reply With Quote
  #25  
Old 05-31-2007, 04:18 PM
Harrison's Avatar
Harrison Harrison is offline
Administrator
 
Join Date: Oct 2004
Posts: 7,010
Default

Teresa, thanks for sharing this information, which is interesting on a few fronts. Did this info help you with your appeal? How might this help others going forward?

Many thanks.
__________________
"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
Reply With Quote
  #26  
Old 06-01-2007, 06:29 AM
Teresa Teresa is offline
Junior Member
 
Join Date: May 2007
Posts: 12
Default

Harrison,
My claim is with Workers Compensation, so it does not pertain to my case. I provided this information for those that are covered under a Self Insured Health Plan. I think the information can be used to assist others on this forum for the following reasons:
1. ERISA is very specific about the process and time frames for requesting coverage. The time frames are different for different situations depending on whether it's pre or post care. Members of the forum need to follow the time frames very carefully especially during the appeals process.
2. ERISA governed plans supersede any state statue unless the state statue provides for greater benefit to the patient. Therefore the Insurance Commissioner, etc. are of little help when appealing.
3. ERISA governed plans have very specific rules regarding appeals. What is interesing is that the Adjustors at most TPAs really don't understand ERISA very well. The patient can use the link to the DOL Website or other ERISA Information sites and find specific rules to include in their appeal. This can be very intimidating to the TPA. These information sites also have Consumer Help Tips on what to include in your appeal, etc.
4. The Summary Plan Document is another key piece of your appeal. ERISA has very specific rules about what should be in the SPD, the time frames for advising members of changes to the plan, etc. Patients should obtain and read the SPD and use any information in it to support the appeal.
5. The final decision on appeals lies with the employer because they are self insured. It is wise to provide any information to support your appeal to the employer. The employer is often not aware of your appeal. There are many players in the game: Employer, TPA, PPO, Case Management, Utilization Review. It is important to know which of the players is most influencing your claim. It is important to obtain each players data. You can't fight their data if you don't know what their data says.

I specifically posted the ERISA information in response to CindyLou and Laurie. However, I felt it would be helpful to others on the forum. The first question they should ask their employer is: "Are we self insured?" The rules are very different for self insured plans verses a commercial plan.

One of the pieces of data that you should use is the cost. Find out the cost of fusion or other procedure that they will authorize and compare it to the cost of ADR. Many times if you show them the cost benefit they will authorize. Don't forget to include costs for hospital, physicians, anesthesiologist, lost time from work, cost of any short or long term disability payments as well as future medical costs. The point that you want to make is that ADR cost is equal to or less than the alternate procedure cost. Your goal here is make the employer question the TPA as to why they are denying payment for the procedure if the cost is less. Your employer should be questioning the TPA as to why they can substantiate a denial for ADR when the alternative procedure costs the same or more.

Harrison, please let me know if I can be of further assistance regarding Self Insured Plans.
__________________
Teresa
"I can be changed by what hapens to me. But, I refuse to be reduced by it." Author: Maya Angelou
Injury July 2004 neck and low back
Conservative Evaluation and Treatment to include PT, ESIs, etc for lumbar and cervical.
January 2005 C5-6 a
Reply With Quote
  #27  
Old 06-01-2007, 06:54 AM
CindyLou's Avatar
CindyLou CindyLou is offline
Senior Member
 
Join Date: Mar 2007
Posts: 627
Default

Teresa,
Yes, I have seen this site with all this valuable information which Laurie will utilize to our advantage in her fight for me. The only point I would disagree on with you, is that the TPA really only follows the direction from the employer. Not the other way around. The TPA only acts in an administrative capacity. So, know who your enemies are. In my case, it is my husband's employer, hands down. They have not even provided any of us with a Summary Plan Description. They have 30 days to provide that, per my conversation with "the man" at the Dept. of Labor in D.C., who I talked to on Tuesday. All in all, valuable info. Now, back to my own fight!
__________________
CindyLou
bicycle accident 6/19/01
2 compression fractures, T12, L1;
vertibroplasty @ above levels, 9/15/01
4/06 hip labral tear repair
4/07 Lumbar ProDisc replacement by Dr. B., 3 levels; L3-6
7/2/08 ALIF of L6-S1
7/30/08 Removed bone cement.
8/7/08 Diagnosed with pulmonary embolism, double pneumonia, collapsed left lung, pleurisy, pleural effusion.
3/10/09 right SI Joint Fusion; seeing light at end of tunnel, for first time in 8 years!!
Reply With Quote
  #28  
Old 06-01-2007, 03:31 PM
Teresa Teresa is offline
Junior Member
 
Join Date: May 2007
Posts: 12
Default

CindyLou,
You are right on target!! It is the employer that makes the final decision, which is precisely what I said in #5 above. However, the employer is influenced by all the other players which is why you need to know the data they are using to substantiate their denial. As you put it "know who your enemies are." However, often the employer does not know the specifics of the appeal. Therefore, it is your job to provide them (the employer) data that will make them question the "wisdom" of the TPAs recommendation not to pay for the procedure. Quite frankly the easiest way to get the employer's attention, is to show them with hard cold facts that it will save them money.

As far as the DOL telling you that they must provide you copy of the SPD within 30 days, please refer to this paragraph which is taken from the DOL article I posted earlier:
"ERISA also requires that SPDs be updated periodically. Furthermore, ERISA requires disclosure of any material reduction in covered services or benefits to participants and beneficiaries generally within 60 days of the adoption of the change through either a revised SPD or a summary of material modification (SMM). Material changes that do not result in a reduction in covered services or benefits must be disclosed through an SMM or revised SPD not later than 210 days after the end of the plan year in which the change was adopted."

The key here is if the change did not result in a reduction of services or benefits, then they have up to 210 days. So I would suggest you get a copy of the prior year SPD as your starting point. At least you would have something in writing. Many employers have a HR section on their Websites for employees where you find policy and procedures, vacation formulas, grievance policy, etc. I would check there first. If you can not locate it there, then put your request in writing to the HR Director to provide you a copy of the SPD for the prior plan year until such time that the new SPD is published. Also, request any amendments that have been made to the SPD. Most updates/changes are done by Amending the Original SPD which in fact may have been drafted years ago. As an example my employer's SPD was drafted in 2003. There has been no new SPD published; however, there have been many amendments published.
__________________
Teresa
"I can be changed by what hapens to me. But, I refuse to be reduced by it." Author: Maya Angelou
Injury July 2004 neck and low back
Conservative Evaluation and Treatment to include PT, ESIs, etc for lumbar and cervical.
January 2005 C5-6 a
Reply With Quote
  #29  
Old 06-02-2007, 05:31 AM
CindyLou's Avatar
CindyLou CindyLou is offline
Senior Member
 
Join Date: Mar 2007
Posts: 627
Default

Teresa, many thanks for the input. Our current coverage was changed to a new company, HealthPartners, who performs in an acting administrator capacity, commencing 1/1/07. And we have never received a copy of the entire Summary Plan Description, nor can it be accessed by going on line. So, I believe that is what the Dept. of Labor man was referring to, when he said "by law" they have 30 days to get me a written copy. I don't believe it would help us to get a copy of last year's SPD, since it was with a different company, unless I just want to look for "patterns" of coverage/non-coverage. Fortunately, I have enlisted the services of The Insurance Warrior to help me wade thru this muck, and get the most persuasive appeal letter in front of their faces soon!
__________________
CindyLou
bicycle accident 6/19/01
2 compression fractures, T12, L1;
vertibroplasty @ above levels, 9/15/01
4/06 hip labral tear repair
4/07 Lumbar ProDisc replacement by Dr. B., 3 levels; L3-6
7/2/08 ALIF of L6-S1
7/30/08 Removed bone cement.
8/7/08 Diagnosed with pulmonary embolism, double pneumonia, collapsed left lung, pleurisy, pleural effusion.
3/10/09 right SI Joint Fusion; seeing light at end of tunnel, for first time in 8 years!!
Reply With Quote
  #30  
Old 07-18-2007, 02:06 PM
Harrison's Avatar
Harrison Harrison is offline
Administrator
 
Join Date: Oct 2004
Posts: 7,010
Default

More information from our good friend -- Laurie Todd!
__________________________

The Insurance Intelligencer

7/16/07

The Three Most Powerful Weapons

There are many components to an insurance appeal, and they should all be present to ensure success. The appeal must not be a “letter,” because a letter is not extensive enough, not substantial enough to be persuasive. No letters, they don’t carry enough weight. It must be an APPEAL DOCUMENT, with a title page, table of contents, cover letter, bullet list of facts, attachments, scary mistake-filled medical story, peer-reviewed studies, resume of your doctor-of-choice, cost comparison, and blockbuster conclusion with a call to action.

The facts are important, the tone of your writing (solid as a rock, totally dispassionate) is important, every detail of the appearance of your document is important.

After participating in a number of these successful appeals, I feel that there are three elements of the appeal that close the deal better than any other. They are the linch-pins of your appeal, they must be there, and they must be polished to perfection, and packed with power.

1. The Quotation Mark

People often call me on the phone and tell me about the outrageous things that their doctor or insurance company representative has said to them. Some examples ...

“Don’t even bother to appeal, because there is zero chance of it’s being accepted.”

“At your age, we don’t need to find out the cause of your rectal bleeding ... we will just give you a transfusion once a week.”

“There is no treatment for your disease.”

“Yes, we have paid for that surgery before. We paid for it by mistake, so we won’t be paying for yours.”

“We lost the fax, we lost the email, the letter got lost in the mail.”

“There are NO good outcomes with that surgery (when the only bad thing about the surgery is that it is out of network).”

“You don’t need any more surgery (when you really do).”

“You need surgery right away (when you ought best wait to see an expert).”

“Your husband is one of our highest-paid executives. If we funded the surgery for you, other employees would be jealous.”

These are all true examples. When anyone associated with your insurance company – doctor or bean-counter – says something outrageous, they have just handed you a nugget of solid gold.

There is nothing more powerful as a naked reporting of what goes on behind closed insurance doors.

Don’t tell me these things ... FIRE UP THE QUOTATION MARKS, AND PUT THEM IN YOUR APPEAL!

2. The Carbon Copy

Here’s the scenario: You write a beautiful appeal document – chock full of facts and intimidating medical mistakes, loaded with proof. Then, you send as directed by your insurance company, to “Mr. Joe Post Office Box.” You might as well throw your appeal in the trash. Why should Mr. Post Offfice Box help you out? There is nobody to check up on him, no accountability.

You must lavish time and effort on the list of important people to whom you will send a copy of your appeal. You will craft your own list, but I have some suggestions. Always copy the Medical Director of the insurance company. Sometimes it takes a little digging to find these people ... your appeal will have more impact just because they know that you were capable of finding a Medical Director. Then, copy a good list of executives at the insurance company. Copy your state’s Insurance Commissioner. Don’t really send him a copy, he doesn’t want to see your appeal. You just want the insurer to know that you know his name – and have probably contacted him. If this is a group policy through your employer, contact the highest HR executive at your company.

Did you find any lawsuits against your health insurer while you were Googling? Copy the attorney who won a lawsuit against them ... this is a name that they will recognize. Has your insurer been investigated by the Attorney General of your state? Copy him – another familiar name for your insurer. Copy the head of your state’s medical board.

Be realistic with your cc’s ... they know that Oprah isn’t going to be participating in your appeal.

The intention is to have your scary appeal land on many powerful desks at once, and to have many higher-ups picking up the phone to call your addressee. Now, Joe Post Office Box cannot ignore your appeal.

3. The Cost Comparison

This really is all about money. Your insurer has denied your treatment not because it is experimental, investigational, not medically necessary, or out of network. They have denied because they don’t want to pay for it.

The best way to nip this unspoken objection in the bud is to simply prove that the treatment you are proposing will COST LESS than the treatment your insurer is proposing. Since they are probably proposing no treatment at all, and you will get worse without any treatment, this shouldn’t be too hard to prove.

Spelling out all of the terrible expensive things that will happen to you if you DON’T get the treatment serves three purposes:

It puts the kibosh on their true motivating objection: We are denying your treatment to control our costs.

2. It serves notice to your insurer, in a very subtle way, that you understand what is behind this denial – money.

You have already told about your past malpractice-worthy medical story. With
the cost-comparison, you get to tell your possible future malpractice-worthy story – if they don’t pay.

************************************************** **********************************************

Reviews

Fight Your Health Insurer and Win
Laurie Todd
Healthwise Publications
PO Box 2045, Woodinville, WA 98072
9780979143502, $14.95 www.theinsurancewarrior.com

According to Reader's Digest in April of 2006, seven in ten adults who were driven into debt by medical expenses had insurance at the time. Author Laurie Todd had health insurance when she was diagnosed with a rare form of cancer, but in order to obtain the expensive treatment necessary to save her life, she had to battle her insurance company tooth and nail. Fight Your Health Insurer and Win: Secrets of the Insurance Warrior is a distillation of what she learned—a lifesaving, no-nonsense guide written especially for sufferers of cancer and other deadly medical afflictions. Chapters cover how to qualify one's own doctors (and make sure one's provider is not only generally competent, but an expert in one's specific affliction), manage one's own care, find the best care possible for one's disease, and force one's health insurer to bear the full cost (a common practice among insurers is to pay an "out-of-network benefit" that covers only 60%-80% of the cost—which is just not enough when some surgeries can cost, $200,000 or more). Also discussed are how to research the life's work of one's physician on Google and ask him questions about his practice (it's important to listen to the tone of the answers as well as the answers themselves); why terms like "experimental/investigational procedures" and "medically necessary" are little more than manipulative word-dancing meant to frighten away people from demanding insurance payment; how to respectfully and persuasively present one's case to insurance industry bureaucrats and medical professionals who have a vested financial interest in your imminent death (if you die quickly, they don't have to pay for your treatment); and much more. Sample letters, step-by-step procedures, guidelines for telephone conversations, and above all the admonition to never give up infuse Fight Your Health Insurer and Win with literally life-giving energy and wisdom. Highly recommended, and an absolute "must-have" for anyone who has paid their health insurance dues.

Susan Bethany
Reviewer

http://www.midwestbookreview.com/rbw/jul_07.htm#bethany

************************************************** **********************************************

Where to Buy the Book

My book is available from my website and several independent bookstores in the Seattle area (University Bookstores, Village Books in Bellingham). No chain stores, none of that. You may order the book by ...

Go to www.theinsurancewarrior.com and use the Buy Now button.

Call me at 425 497-1858, and I will take your order by phone. Send me a check for $19.95 if you are outside of the state of Washington, and $21.32 if you are in Washington:

Healthwise Publications

P.O. Box 2045

Woodinville, WA 98072



************************************************** *********************************************

The Insurance Warrior Speaks – in Public

A speaking career seems to be developing naturally, as the book spreads across the country.

If you know a group or organization who needs to hear this empowering insurance message, just give me a call.

My best, and good Insurance Warrior-ing to all.

Laurie Todd
laurie (at) theinsurancewarrior.com
425 497-1858
__________________
"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
Reply With Quote
Reply

Bookmarks

Thread Tools

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is On
HTML code is Off


Similar Threads
Thread Thread Starter Forum Replies Last Post
Please Review Terms of Service Harrison The Big File 1 11-11-2007 02:45 PM
NSR - a great ticket service - Thanks Cervie Queen! mmglobal The Big File 1 11-07-2005 03:33 PM
International Patient Service Harrison The Big File 2 10-24-2005 09:52 PM


All times are GMT -4. The time now is 11:35 AM.


© Copyright 2006-2023 ADRSupport.org All rights reserved.