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  #51  
Old 09-06-2011, 11:10 AM
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The Insurance Intelligencer
9/2/11

The Five Wise Men

Ever called your insurance company? Call six different people, and you will get six different answers. They will tell you that they never heard of whatever you are asking for, the person that you need to speak to is on vacation, and they don't know the name of their supervisor.

People -- especially people who are ill and actually need something -- become discouraged and exhausted by talking to their insurance companies on the phone. Finally, they give up.

The only people whom we are allowed to talk to at insurance companies are people who know nothing, and who are not decision-makers. Their job is to get rid of us by saying, "Just wait for our letter."

Why then should we ever call the insurance company? To write down all of the ridiculous things that they say -- so that we can put them in our appeal.

The Runaround Story

A winning appeal is not an attempt to prove to the insurance company that you really need a treatment, that the treatment is approved by the FDA, or that this is the only effective treatment for your disease. A winning appeal needs to be so unsettling and unnerving to the insurance company that they want to get rid of it as quickly and completely as possible. The only way to make sure that nobody else ever sees this cringe-worthy document is to immediately pay for your treatment.

You will offer a mountain of scientific evidence for your treatment. However, it is the ridiculous, non-sensical, unreasonable, arbitrrary, deceptive actions of the insurance company -- revealed by you in the most embarrassing manner -- that will win your appeal.

The five nuts from Worcester

Deb has a "Blue HMO" plan with Blue Cross Blue Shield of Massachusetts. In other words, she can only see doctors in the state of Massachusetts who happen to be under contract to her HMO. What happens if she needs a complex and difficult cancer surgery -- and no surgeon in Massachusetts who is a provider for HMO Blue can perform it?

What happens is that BC/BS of Massachusetts sends Deb a letter, informing her that the out-of-network surgery with Dr. Sardi has been denied, because, "the requested service is available in-network." BC/BS of Massachusetts has no idea if this treatment is available in their HMO network or not. They simply say, "it is available in-network" ... and let you exhaust yourself proving them wrong.

I instructed Deb to call BC/BS of Massachusetts, ask for the list of in-network surgeons -- and to write down everything they said. What I wanted was a cringe-worthy story. This is exactly how it looked in Deb's appeal:

1. What is that treatment?

On 8/23/11, I spoke to Tina at BC/BS member services. I explained that I have a recurrence of appendix cancer with liver metastasis, I need cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, and the BC/BS denial letter states that "the requested service is available in-network." I then asked for a list of the in-network surgeons who offer this treatment.

Tina asked, "What is that treatment?" She then placed me on hold for twenty minutes. When she returned, she gave me the address of the appeals department, and suggested that I write an appeal.


2. Cut off

On 8/24/ll, I called and spoke with Shayna Thompson. Once again, I explained my condition and the requested treatment, and asked for in-network providers who could perform it.

Shayna put me on hold. I waited on the line for twenty minutes, at which time the call was disconnected.


3. "What is it that you have?"

Later on 8/24/11, I spoke with John in member services. I explained my condtion, told him that the BC/BS letter promised that I would find in-network providers who offer cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. John replied with a question, "What is it that you have?"


4. "You have to choose from the following categories ..."

John asked, "What kind of surgeon do you want?" I replied, "How about a surgical oncologist who specializes in gastrointestinal malignancies, and who performs the requested service?"

John replied, "You have to choose one of our categories. We have hand surgeons, orthopedic surgeons, plastic surgeons, thoracic surgeons, vascular surgeons, and general surgeons." I asked, "Do you mean to tell me that you can't narrow it down any more than that?" "No, that's all we have," John replied.


5. The list of five

I said, "Well, since I don't need a hand surgeon, I suppose that we will have to go with a general surgeon."

John gave me the names of five surgeons. They were all at the same address in Worcester: Drs. Timothy Emhoff, Bruce Simon, Janice Lalikos, Demetrious Litwin, and John Kelly.

Dr. Timothy Emhoff is a pediatric surgeon.
Dr. Bruce Simon is a chest surgeon.
Dr. Janice Lalikos is a craniofacial surgeon.

6. "We don't do cancer."

Drs. Litwin and Kelly are both at UMass Endosurgery. Cytoreductive surgery is not an endoscopic procedure. However, I performed my due diligence, and called their office.

I asked, "Do you offer cytoreductive surgery and hyperthermic intraperitoneal chemotherapy?" The nurse replied, "Honey, you need a urologist." When I asked why I would need a urologist, she said, "We don't do cancer."

I asked, "Can you refer me to anyone who does this treatment?" The nurse replied, "You need to talk to your primary care physician, and she can tell you where to go."

Apparently, my requested treatment is not as available as the BC/BS letter might lead one to believe.

At the end of our conversation, I said to John at member services, "I thought that you would give me a list of credible in-network people who actually do this treatment." John replied, "I can't help you find any doctors. You need to look to your primary care physician for guidance; she will be able to find a doctor for you.

My primary care physician -- Dr. Mary Smith* -- has guided and referred me to Dr. Armando Sardi in Baltimore. (See Dr. Smith's referral letter, page xx.)

******

Imagine the Vice President of Health Care Services at BC/BS of Massachusetts reading this rendition about the Five Wise Men of Worcester. He knows that the president of BC/BS of Massachusetts is also reading it, as is the chairman of the board of directors. What is his first thought? I need to get rid of this, so that nobody else sees it. What is the fastest way to get rid of it? To approve it.

It is time to harness your Runaround Story for good, and to use it in your appeal!

Of course, the Runaround Story was but one persuasive section of a 43-page document. I faxed and emailed the appeal on Sunday night ... and we won on Tuesday morning.

Deb will be on her way to Baltimore for her lifesaving surgery next week.

Peaceful Insurance Warrior-ing,

Laurie Todd
health insurance help
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  #52  
Old 10-31-2011, 08:55 PM
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The Insurance Intelligencer
10/30/11

Sharlene hits a home run

People often ask, "Which insurance company is the worst?" The diplomatic answer? They are all equally bad. The true answer? Anthem Blue Cross Blue Shield of Virginia.

I lost to Anthem BC/BS of Virginia two years ago. Just when it looked like I was going to lose to them again, my helpee did something that I would never advise anyone to do -- and saved the day.

A bitter loss

In 2009, I fought Anthem BC/BS of Virginia for the first time. I soon learned that I was up against a mighty foe. When I faxed the appeal to the executives at Anthem, none of the half-dozen fax numbers worked. That has never happened before or since.

I did everything that I could think of, and I never got the slightest reaction out of Anthem.

My helpee in this case was Buck -- a true Southern gentleman. He had late-stage colon cancer, and he needed expert surgery. It was a bitter loss.

I swore that I would never lose to any Anthem BC/BS company ever again. Over the next two years, I fought Anthem BC/BS of California and won -- twice. I fought Anthem BC/BS of Connecticut twice, and won both times. All the while looking over my shoulder, watching for my nemesis.

Last week Anthem BC/BS of Virgiinia came a-knockin'.

I had one day to write the appeal, and one day to win it. With a case like this, I wished for a helpee with personality of a pit bull. I got Sharlene. She was as sweet as could be. However, she was no pit bull. Or so I thought ...

Sharlene hits a home run

Suddenly, things started moving. The door was cracking open, Anthem was finally answering calls ... they were getting ready to do business.

I called Sharlene, "What did you do?"

Sharlene said, "I was sitting at my kitchen table, worrying about the appeal. Among the stacks of papers, I noticed a letter from my Congressman. The letter said, 'If there is anything that I can do for you, please call.' So I called my congressman."

I have never advised calling your congressman, when treatment is denied. Usually, politicians couldn't care less about our medical treatments, and insurance companies couldn't care less what politicians have to say. However -- against all odds -- Sharlene made it work.

It so happened that the congressman was running for re-election -- which made him a little more susceptible to a media-worthy story like this. Plus, he didn't have to do any research. Sharlene simply faxed the appeal, and gave him the names and phone numbers to call the executives and Anthem BC/BS.

Sharlene said exactly the right words, in exactly the right way. The congresssman jumped all over this case, and spent the rest of the day on the phone with the insurance company.

At 5:02 p.m. on Friday, Anthem BC/BS of Virginia finally -- and very reluctantly -- approved the surgery, and signed the single-case contract with Dr. Sugarbaker's office. Sharlene had her surgery on Tuesday. She is doing very well.

I love it when my helpees rise magnificently to the occasion. And I love it when a case is won in a new, unexpected way that I could never have imagined.

This one's for you, Buck.

Happy and peaceful Insurance Warrior-ing,

Laurie Todd
health insurance help
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Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
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  #53  
Old 10-31-2011, 09:22 PM
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A good example of perfect timing, luck - and knowing when to jump in and advocate for yourself!! Great story.
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  #54  
Old 01-10-2012, 11:57 AM
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The Insurance Intelligencer
1/10/12

Healthcare justice for all ... it begins in California

Meeting Oliver

On December 27, my best holiday present arrived. I got to meet Oliver.

Oliver and his family were in the Seattle area, visiting his grandparents for Christmas. We met for breakfast at a pancake house in my neighborhood.

Oliver came running up to me in the parking lot. He asked, "Did you help me get my surgery?" "Yes," I replied, "I wrote a big long letter, and helped you to get your surgery." Oliver threw his arms around my neck, saying, "Thank you, thank you."

Truly, it does not get any better than this.

HIAA 2012: Healthcare justice for all

Oliver was born with craniosynostosis -- a condition where one or more of the sutures of the skull fuse prematurely. In order to fix craniosynostosis, the skull needs to be dismantled, reshaped, and put back together. This is an art and a science -- with the surgeon correcting any defects, and leaving just enough "leeway" for future growth.

Oliver needed to get to Dr. Fearon in Dallas, Texas. Dr. Fearon has performed hundreds of these surgeries for craniosynostosis. He hasfollowed his little patients for eleven years, developed new procedures to make the surgery safer and more effective, and documented his outcomes in thirty-four scientific articles.

Anthem's position? We have three local plastic surgeons who are in-network for Anthem. We don't care what their qualifications are, and we don't care if this is the first surgery they ever performed for craniosynostosis. If they have an M.D. after their name, and they are bound by contract to Anthem ... that is where you will go.

If it were your child -- and his skull, brain, vision and physical appearance were at stake -- would that be good enough for you? Would you accept "Dr. Nobody" because the insurance company said so? You would have to accept it -- unless you happened to find me, and I wrote, fought, and won your appeal.

As it stands now, insurers have ultimate power over what medical treatments we are allowed to have, who gives those treatments, how much they pay for them, and when they pay.

What are we going to do about this? How can we hold health insurers accountable for their decisions? What can we do so that families like Oliver's do not have to fight the same fight again and again?

As of today, there is an answer: the Health Insurer Accountability Act of 2012 (HIAA).

What is HIAA, and what will it do?

• You need a massively expensive surgery/drug/treatment. You had no idea that it would not be covered; you are devastated. HIAA will require policies to be written in language that is clear to people who buy and rely on them. You will have an absolute right to know what you are getting.

• Your insurer just raised your premiums by 35%. There is no limit to how much they can raise them. You can't afford insurance anymore. When insurers apply for a rate increase, HIAA will require those submissions to be under oath and penalty of perjury. Only if the rates are proven to be justified and based on accurate data will they be approved.

• Your doctor tells you that there is only one surgery/drug/treatment that can save your child's life. The insurance company denies it. HIAA will make insurers directly accountable for any harm caused by their decisions.

• The insurer approved your surgery/treatment. It is one year later. Neither the medical providers nor the hospital have been paid; they are now sending the bills to you. The bills are in excess of $100,000.

HIAA will require health insurers to pay covered claims promptly.HIAA will do all this, and much more ...

Healthcare justice for all

You can do something to end the divine rights of insurance companies right now. If this bill gets 504,760 signatures by May 1, gets on the ballot in November 2012, and passes -- it will affect how health insurers do business throughout the United States.

I do not live in California. However, this is my fight. I have dedicated my life to making insurers do the right thing, practice evidence-based medicine, and pay for the lifesaving treatments that people need. This bill will multiply my victories a thousandfold -- a veritable tsunami of good medical care.

The Health Insurer Accountability Act (HIAA) has been accepted by the Attorney General of California. As of today, 504,760 signatures are needed by 5/1/12 in order to put HIAA on the ballot in November.

You can make this happen, starting today. Go directly to the website: Health Insurer Accountability Act of 2012 | Healthcare Justice for All

On the website, you can ...

• See a brand-new video of my story on the home page.
• Read the bill.
• Download a petition, collect as many signatures as you wish, and be part of the solution.
• Donate for the administrative costs associated with this massive effort.
• Share your insurance story.
• Volunteer your skills, time, contacts, or ideas.

Do you know anyone in California? Forward this message to them. They are the ones who can get the signatures, get this measure on the ballot, and vote for HIAA in November.

Do you know anyone in the United States? Forward this message to them. California is the largest market for health insurance in the United States. When this bill becomes law in California, it will transform the way insurers do business in your state, in my state -- in every state in the U.S.

If you want to chat, ask questions, or interact, there is a Facebook group: HIAA 2012.

All of the information is on the website. You can download a petition, gather signatures, share your story -- and become part of the solution today.

Peaceful Insurance Warrior-ing,

Laurie Todd
health insurance help
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"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
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  #55  
Old 01-10-2012, 12:15 PM
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i think that those things all make sense, however this one will be very hard to enforce:

"Your doctor tells you that there is only one surgery/drug/treatment that can save your child's life. The insurance company denies it. HIAA will make insurers directly accountable for any harm caused by their decisions."

there are so many conditions for which some docs think there is only one answer, and others would offer options... there are some really bad docs out there who will say something is the only option b/c it makes them $$... i haven't read through the whole bill, but that's a really tough argument to make in a lot of cases.
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The content herein represents my professional thought and opinions in a general sense only; they do not constitute professional advice or services. if you need medical advice, please consult a licensed physician.
  #56  
Old 03-29-2012, 08:26 PM
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The Insurance Intelligencer
3/29/12

Samantha's story

When mom helpees are fighting for their children ... they trust me immediately, jump into my lifeboat without question, and row like crazy. It's a beautiful thing.

The art of waiting

In January I received an email from Lisa in California. Her 14-year-old daughter needed brain surgery.

I thought that this might be a case for me -- so I called Lisa. What I heard was unilike the cancer stories which routinely come across my desk. This was a story of nine years of Big Trouble. It was a story which would both me, bedevil me, and wear on me. However, what drew me to this story was the emotional resilience of one mom -- who had been moving heaven and earth for nine years to make things better for her daughter.

Samantha was diagnosed with severe Tourette syndrome at age six. This means incontrollable, loud, socially embarrassing, exhausting, repetitive vocal and physical behaviors. On and off all day, every day ... for nine years. Tics so violent that they rob her of friends, of school, of a social life. Tics that injure her to the point of broken bones.

I dedicated an entire page in the appeal to the list of medications that this child has been on over the years -- none of which have been effective longterm:
  1. Abilify
  2. Klonopin
  3. Lorezapam
  4. Diazepam
  5. Guanfacine
  6. Topamax
  7. Risperdal
  8. Orap
  9. Tetrabenazine
  10. Haldol
  11. Botox
  12. Prozac
  13. Wellbutrin
  14. Zoloft
  15. Strattera
  16. Gabapentin
  17. Vicodin
  18. Oxydodone
  19. Oxycontin
  20. Dilaudid
  21. Roxicet
  22. Tramadol
  23. Prednisone
  24. Lododerm
  25. Hydrocodone
  26. Amrix
  27. Tizanidine
  28. Hydromorphone
Hundreds of visits over the years to psychologists, psychiatrists, neurologists. Repeated hospitalizations for physical injuries.

The heart of an appeal is the Bad Medical Story. I am used to the Bad Medical Stories of cancer patients -- I had one myself, seven years ago. But this ... so very long, so very hard. This story was an Iron Man triathalon. It was a heavy story to write, much less to live.

Deep brain stimulation has been tried and tested for severe Tourette's. It can work -- when nothing else works. Lisa fought for a year to find a neurosurgeon who would perform this surgery on a 14-year-old. It is routinely done for intractable Tourette's in Europe, but here in the U.S. it is more of a challenge. When she finally found the ideal surgeon -- Dr. Philip Starr at UCSF -- Anthem Blue Cross of California denied it.

I took this case for two reasons. First, this family deserved a break as much as any family that I have ever encountered. Second ... I was moved by mom Lisa. She had been through so much She had found a way to not only fight like a mama lion for nine years ... but to keep it light, keep a sense of humor, keep a family surviving and thriving.

We talked in January. Surgery was scheduled for April 7. I'm sure that Lisa thought that we would immediately start "fighting the insurance company."

I said, "Send me all of the info -- the denial letter, the Bad Medical Story, the proper referral letter from your in-network doctor. I will build a file of the scientific articles, and I will read them. However, we won't be sending this appeal until ten days before the surgery. Anthem would love to have three months to fool around with this case ... but I am not going to allow that. Speed is a strategy."

Lisa trusted me. For the next two-and-a-half months ... we talked, and we waited.

All out warfare


I carefully craft my Addressee List of fourteen high-level decision-makers -- both inside and outside of the insurance company. On Sunday nights, I fax and email the appeal document to all of them.

After I send the appeal -- we do sit around waiting helplessly for the insurance company to have their way with us. No! At 10:00 a.m. on Monday, we begin the Telephone Attack. This is not like calling customer service. I have dug up phone numbers for CEOs, vice presidents, and chief medical officers. I tell my helpee who to call, what to say, what not to say. They report back to me, and I tell them what to say next. The purpose of all this is to keep the pressure on, keep control, and push the appeal through as fast as possible.

These battles are not about clinical appropriateness, and they are not about money. They are about control. An insurance company will fight me tooth and nail to deny a treatment with a mountain of scientific evidence to support it -- which would cost a fraction of the totally unproven treatment which they routinely pay for. It's about control.

My 40-page blockbuster document wrests back control for a few days; the Telephone Attack keeps that control going -- just until they decide to pay for it.

The appeal on their desks first-thing Monday morning. It needs to be approved and wrapped up by Friday. No weekend, no break in the action.

The longer an insurer has to chew on a case, the more ways they will find to deny it.

Speed is a strategy.

Victory is ours

I had Lisa working the phone constantly for two days -- with me coaching, sending additional frosty emails where needed. Strategizing, digging up more phone numbers, calling again.

The surgery was approved at 4:00 p.m. on Tuesday.

This is the story a sweet girl and a lion-of-courage mom who fought against all odds for nine years. The story became mine for two months, we won a great victory, and we shared a moment of pure joy.

It does not get any better than this.

Peaceful Insurance Warrior-ing,

Laurie Todd
health insurance help

P.S. Five thrilling stories have gone by since I wrote my last newsletter; I don't have time to write about them all. Most of the exciting play-by-play happens on my Facebook page: "Laurie Johnson Todd." Come over and join the action!
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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
  #57  
Old 06-03-2012, 02:42 PM
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Good job, Laurie! Helpful analysis too - especially on the "danger of medical privacy."
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The Insurance Intelligencer 6/4/12

The bigger they are, the quicker they fall

On Wednesday I received a call from Michael and Carrie in Vermont. We have been friends since her surgery with Dr. Sugarbaker in 2009. Her second surgery with Dr. Sugarbaker was scheduled for next Tuesday.

Their insurance company -- MVP, a subsidiary of Cigna -- had been stringing them along for months. Now, one week before the surgery, it was clear that they weren't planning to pay. Cigna had paid for Carrie's first surgery with Dr. Sugarbaker in 2009. It's just that Cigna (masquerading as "MVP") didn't want to pay for it again.

It was clear that I would have to stay up all night and write the appeal on Wednesday night. I would fax and email the appeal to fourteen movers and shakers by 5:00 a.m. Pacific time on Thursday. We would then have to spend all day Thursday on the phone with the appropriate executives.

Michael is insured under a self-funded plan. In a self-funded plan, it is the employer who pays for your medical treatments. Therefore, your employer gets to decide whether or not you will be allowed to have a medical treatment.

Our task was to make Michael's employer reverse their denial within two days. Guess who the employer is? IBM.

In this story, we will see that private medical information is the most powerful weapon that we have to fight insurance denials -- and that this information is the most precious gift that we can give ...

The gift of precedent

By 5:30 p.m., I was knee-deep in Carrie's appeal. All of a sudden, it dawned on me -- I had won a case for an IBM employee for this treatment before.

Back in 2007, Al from New York contacted me. His partner Dan had appendix cancer, and he wanted to Dr. Sardi in Baltimore for surgery. Healthnet had denied it. Same employer as my current case, same disease, different surgeon, different insurance company. All in all, an excellent case of precedent. However, it gets better ...

I called Al. Thankfully, he was home. I told him that my current helpee, Carrie, was going back for a second surgery with Dr. Sugarbaker, and MVP was denying it. I said, "Wait just a doggone minute. Dan had a second surgery last year -- who was the insurance company on that one?" Al replied, "MVP."

But it gets even better. Dan's recurrence was in an unusual place: the lung. His second surgery was with a famous thoracic surgeon in Boston -- Dr. David Sugarbaker, Dr. Paul Sugarbaker's brother.

I couldn't make this stuff up. This is truly the world's most elegant case of precedent.

Slam dunk


Of course, even with Dan's case, 153 other cases of prececent, and a 49-page document -- no employer or insurer ever has to pay for anything. I prepared Michael for the usual full-court press for Thursday -- Michael phoning executives at MVP and Cigna, me coaching behind the scenes, more calls, more strategizing.

Four hours later, IBM and Cigna/MVP decided to pay.

Medical privacy

Over the past forty years, private insurers have waged an all-out propaganda war on the American public. They have been very successful at molding our opinions. Most people believe the following myths:
• Insurance companies will cover our expenses when we get sick.
• If we have health insurance, we are protected from financial ruin.
• Insurance companies are more qualified to make medical decisions than doctors are.
• The main problem with our healthcare system is lazy unhealthy people with bad habits who choose not to have health insurance.
• The other main problem with our healthcare system is greedy doctors.
All unfair, unfounded, and untrue.

With the guidance of insurance companies, we have come to believe that our private medical information is terribly dangerous. Go on any insurance company website. They will assure you up one side and down the other as to how scrupulous they are about protecting your private medical information. The impression is that evil forces are lurking around, just itching to get their hands on your medical information. But never fear! The insurance company is there to protect you!

Ever wonder why insurers are so in love with medical privacy, and medical privacy laws?

When an insurance company denies a treatment as "experimental," or as "not medically necessary" ... it is very embarrassing for them to see on paper that they have paid for it three dozen times before.

Insurance companies despise precedent. It shows that the entire denial/review/appeals process is based on deception.

*****

I have spent seven years building my list of precedent for cytoreductive surgery and HIPEC. I now have 153 cases where insurers have fully funded this treatment -- most of them with out-of-network, out-of-area medical providers. First name, last name, diagnosis, date of surgery, name of surgeon, name of insurance company.

I love my list of precedent for CRS/HIPEC. I include all 153 cases with every appeal for this issue -- rearranged depending upon which disease the person has, and who is the insurance company. Whenever I retool and use my list, I think of the precious helpees and friends who have come before. Their cases go on to help others. My precedent list is a powerful tribute to them.

Insurance companies despise precedent. They have gone to great lengths over the past forty years to persuade us that we must never reveal it. I say: Learn to love your private medical information. It is the most powerful tool you have, in order to help others to access the legitimate, clinically-appropriate treatments which insurers have paid for so many times before.

I will put my medical info out on the Internet. I will hand it out on the street corner, if it will help one other patient.

It pains me to see an entire country succumb to propaganda. Propaganda so pervasive, so expertly deployed, so accepted, so believed. Proganda so powerful that it disempowers us in the very moment when we need every bit of our free will and critical thinking in order to save our own lives.

Remember Al and Dan, my helpees from 2007? Dan died last year. I knew that I could call Al and talk about precedent because we are friends -- and because of his generous heart.

This is not about private medical information. This is about truth. This is about justice. This is about overcoming fear, and about reaching out a hand to help.

Peaceful Insurance Warrior-ing,

Laurie Todd
health insurance help
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"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
  #58  
Old 04-29-2013, 08:57 PM
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Harrison Harrison is offline
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The Insurance Intelligencer
4/29/13

The Insurance Warrior is back, ready to fight for truth and justice ...

Doctors who work for insurance companies

When I needed a complex lifesaving surgery -- one which required special training, skill and experience -- my only question was, "Who is the most qualified surgeon, with the best longterm outcomes?" I assumed that this would be first priority for everyone. I was wrong.

For most patients -- the first question is not, "Who is most qualified?" but, "Who will my insurance company allow me to see?" For me, checking with the insurer about where to go for treatment is like conferring with the fox about how to guard the henhouse.

Patients look to their insurers when making medical decisions. This tells me that the American public believes that ...

• Insurance companies would never be deceptive.
• Insurers have our best interests at heart.
• Insurers are great repositories of scientific and medical knowledge.

One of the powerful ways that insurance companies persuade us of their medical knowledge and good intentions is to employ doctors -- and to use these doctors to interface with both you and your treating physician. Who are these doctors, and what is their real job at the insurance company?

What does a "medical director" direct?

Remember the Ministry of Truth in George Orwell's novel "1984"? It was the propaganda machine that taught the people that war is peace, ignorance is wisdom, and obedience is power. And so it is with insurance companies. Insurance company words always mean the opposite of what they appear to mean.

The denial letter from your insurance company is signed by a "medical director." This title is meant to make him sound very medical and very important. It fools patients, and it fools the most sophisticated doctors. It is meant to create the illusion that an expert and important medical executive has really burned the midnight oil studying up on your requested treatment. After all of this due diligence, he has determined in his infinite wisdom that the treatment is just not safe or right for you. In other words, the treatment which your doctor has requested is either "experimental," or "not medically necessary."

Your doctor has requested the treatment. So the insurer pits doctor against doctor. And their doctor is more important, because he is a "director." Makes him sound like he is in charge of the Mayo Clinic, doesn't it?

Well, guess what? Medical directors don't direct anything. They are the peons of the insurance world. And the denial letters which they sign are boiler-plate, identical, generated by computer. There is no due diligence, the emperor has no clothes.
As a matter of fact, they don't even "direct" their own decisons. A medical director once confessed to one of my helpees, "You will get another denial -- but don't worry about it. As a medical director, I am not authorized to do anything but state the insurance company's position."

Whoa. Think about that for a minute. Your so-called "medical director" is not authorized to reverse denials. Any dealings that you have with him are a waste of time. Most medical directors are part-timers at the insurance company. They simply rent out their name and title -- to be displayed on denial letters.

The peer-to-peer review

How do insurance companies get doctors to give up medical decision-making power -- and to deny based not on medical judgement, but on the wishes of the insurance company? They begin by hiring doctors who are not qualified to render an opinion on the treatment which has been requested. Hey, if the doctor had any knowledge or experience with any of these treatments, they might be tempted to approve them.

99% of insurance company doctors are family practice physicians. Family practice physicians have no particular area of specialization -- and are not experienced in or knowledgeable about the treatments which they deny.

So, when you hear that the medical director at the insurance company is calling your doctor for a "peer-to-peer review" -- he is not a peer, and it is not a review. He is calling to tell your doctor all of the reasons why the insurance company isn't going to pay for your treatment.

The "outside expert"

After the insurance company doctor denies your treatment again, they will send your case to an "outside expert." The insurer will tell you that there is a panel of medical experts at the independent review organization which will carefully examine every aspect of your case.

Newsflash: There are no medical experts, there is no panel, there is no examination.

Our entire medical system ultimately rests on independent review organizations. This is your court of last resort. Guess what? These review orgs are private companies which are not licensed, certified or regulated in any way. They rely on a stable of the most questionable doctors imaginable. Hired guns, as it were.

I once had an "outside reviewer" on one of my appeals for brain surgery. This doctor was supposedly a neurosurgeon. When I searched for him, I found no office, no phone number, no nothing. A current medical license, and that was it. I went on a hunch, and searched his state's Bar Association. Indeed, he had been a neurosurgeon. Not a brain surgeon; he had done back surgeries once upon a time. But it gets worse. Twelve years prior, he had gone to law school. He had been an attorney for twelve years, just keeping the medical license in order to do appeals for review organizations.

*******

When it comes to insurance company reviews -- I have seen pediatricians reviewing complex cancer surgeries, podiatrists reviewing craniofacial surgery. This is not about a good faith effort to review medical treatments. It is about using doctors to create the appearance of medical expertise -- where none exists.

You, the patient, are the only one who can overturn an insurance denial. Win it within the insurance company, before it ever gets to independent review.

Is the reviewer absurdly inappropriate and unqualified to pass judgement on your lifesaving treatment? The more unqualified, the better -- it will be very motivating to your insurer, when you point this out in your appeal.

*****

Dr. Jerome Zacks has been so troubled by the use of doctors as "denial-tools" by insurance companies that he has created a petition. This petition asks Congress to hold insurance-company doctors to the same standards as doctors who treat patients. Take a look, and sign if you want to send a powerful message to insurance companies:

Link to the petition follows:
SignOn.org - Uniform Standard of Care for Physicians

Happy and peaceful Insurance Warrior-ing,

Laurie Todd
health insurance help
__________________
"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
  #59  
Old 06-04-2018, 10:34 AM
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Harrison Harrison is offline
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Laurie Todd, the Insurance Warrior, has published a new book: Approved Win your Insurance Appeal in 5 Days.

See:

http://www.theinsurancewarrior.com/

It's only $20.00, a wise play for those of you facing the battle.
__________________
"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
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