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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.


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  #31  
Old 08-13-2007, 06:46 AM
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Harrison Harrison is offline
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Posted for our friend, the author, Laurie Todd.
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The Insurance Intelligencer
8/12/07

Precedent: Proof that Packs a Punch

Your health insurer says, “We will not pay.”

What facts do you have to prove, in order to make them pay?

You will prove many facts in your written appeal:

The insurance-contracted doctors have made numerous mistakes.
Purpose: Intimidation ... you hold the “malpractice cards.”

The mistakes that your insurance doctors made could lead to very expensive bad outcomes. Purpose: To show that you understand that this is all about money.

Your treatment-of-choice produces proven good outcomes.
Purpose: To compare and contrast with the treatments you have already undergone, which have no chance of a good outcome for you.

What you are proposing will cost less than what they are proposing.
Purpose: To overcome the underlying objection, which is all about money.

You must include as many types of proof as you can, if you expect to win your appeal. However, the most powerful, unassailable, intimidating type of proof which you can provide is PRECEDENT.

What is precedent? Proof that they have paid for this before.

How do I know that precedent is the most powerful type of proof? Because I can already see health insurers trying to fight back against our predecent. Fortunately, I know how to lob those shells right back over the wall.

Where do we find precedent?

Let’s say that you have melanoma, you have Acme Insurance, and they won’t pay for an expensive medication. They state that the medicine is “experimental/investigational.” Many patients would stop right there, “Oh well, it’s experimental.”

They tell me that it is experimental, but they have already paid for it? How could this be?

Remember the Insurance Warrior battle cry: “They aren’t saying that it is experimental because it IS experimental. They are saying that it is experimental because THEY DON’T WANT TO PAY FOR IT.”

Because you are an Insurance Warrior, you will leap over this objection. Not only will you find all sorts of peer-reviewed articles and published studies to support your request for this medication, but you will find cases where they have paid for this before.

You are not privy to medical records ... how will you find this proof?

Simplest way is to join an online support group for melanoma. Join two or three. Find the groups by Googling “melanoma support” ... that you get you started. Also, search through Yahoo Groups ... they probably have a dozen groups for any disease or condition.

Get on the groups, introduce yourself, and put out the call: “My name is Mary Smith. My story is such-and-such. I have Acme Insurance, and they don’t want to pay for my Erbitux. Does anyone here have Acme Insurance, and have they paid for Erbitux? Who is your doctor? When did they pay?”

Within hours, you should have some precedent.

Does the precedent have to be from my insurer?

It is best if it is your insurer who has paid for this before. However, the Insurance Warrior always takes whatever she has, and makes it fit.

Let’s say you have Acme Insurance, and all you can find is proof that six other insurance companies have paid. Or, you belong to “California TrueHealth.” Truehealth is a giant health insurer, with separate companies in every state of the union. You have been able to find precedent for TrueHealth in eight of these companies, but not for yours in California.

Go ahead and use your proof. Hopefully, those six other insurers where huge, nationwide companies. After your list of precedent, you state: “I understand that these are all different insurance entities. However, it simply adds to the mountain of proof that this treatment is now STANDARD OF CARE for this disease.”

What does a precedent list look like?

I’ll tell you what it DOESN’T look like – a list of insurance companies who paid.

A precedent list is a scary, personal, intimidating list of individuals who have already had this paid for:

1. Mary Jones
Acme Insurance/Dr. Bill Smith
Erbitux paid for 6/15/07



2. Jim Johnson
Acme Insurance/Dr. Ricard Peterson
Erbitux paid for 7/8/07



... and so on. Your list should include at least a dozen cases.

In the past, there was no Internet. There was no way for patients to discover that, even though their insurer was denying them a treatment, that same insurer had paid for it, for someone else, the week before. Now, the Internet helps to level the playing field.

Of course, we do not have access to medical records. I was able to find a dozen cases of my so-called rare cancer at my small local HMO. If I could open up the official database of patients, I would probably have found fifty.

Fortunately, we do not need a hundred cases to win ... a dozen will do quite nicely.

How are the insurers fighting precedent?

Health insurers are very unhappy that we are suddenly able to find out that they have already paid for the medication/treatment/surgery that they have denied to us. This is a real problem, how are they going to overcome it?

Just lately, I have noticed two tactics employed to try to avoid paying for you, even though they have already paid for someone else ...

Tactic #1: Insurer states: “Yes, we did pay for that before. However, we paid by mistake. We paid by mistake because your doctor gave us the wrong codes (thus inferring that your doctor either made a mistake himself, or is unethical).

Pretty lackluster attempt to get out of paying, in my estimation. You go ahead and provide your list of a dozen times your insurer has already paid, and a dozen times the three largest health insurers in the country have paid – over a ten-year period. So .... two dozen different doctors, and all of these insurance companies, have made the same mistake over and over for many years. Not bloody likely.

Tactic #2: When appeal succeeds, insurer states: “This is a one-time exception only. We will never pay for this again.”

Sorry, Acme Insurance ... you don’t get to do that. We all have the same contract with you. If you provide a service to one contract-holder, you must give the same service to all. You will pay again, that objection is not gonna fly.

Find your precedent, compile a long list with names and dates. After you win your own appeal, share this list with all of your friends with the same condition. This is how we become Insurance Warriors ... by winning the battle, then sharing our victories.

How to Buy the Book

No chain bookstores, 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

Good health, and happy Insurance Warrioring!

Laurie Todd
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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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  #32  
Old 11-09-2010, 07:43 PM
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Jstuckey Jstuckey is offline
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Quote:
Originally Posted by Harrison View Post
Hello ADRSupport Friends.

Finally, some good news for people looking for assistance with their insurance coverage! For patients that are seeking insurance coverage for their one-level Charite disc replacement, a third-party can assist you throughout the entire process.

To start your appeal process, you need only call this number: 800-216-4154 (open M-F, 8:00 am to 5:00 PM). Your case will be “project managed” professionally by people that know the appeals process. There are little to no costs associated with the service.

Again, this program is for people for one-level Charite disc replacements at this time. I hope to see other support services in the future, but any progress is welcome in the meantime.

Good luck to all of you!
Any idea if this is still an accurate way to get advice on Charite denials in US? This post is rather old. I'll try calling tomorrow, but thought there might be other info out there I'm missing. I learn so much every time I come to this sight. So much to read and learn. Thanks
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9/28/2011: Hybrid STALIF TT interbody fusion at L5-S1 and M6-L ADR L4-5 with Nick Boeree, UK - forever grateful to you Nick! Still doing great.
Prior to the fix: Severe DDD L4-5 and L5-S1 with moderate facet degen at L5-S1, but only mild facet degeneration at L4-5.
http://healthyback2011.blogspot.com/
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  #33  
Old 11-10-2010, 10:08 AM
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Jstuckey Jstuckey is offline
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This number does not seem to be in service any longer....
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Joey Sue - 50 years old
9/28/2011: Hybrid STALIF TT interbody fusion at L5-S1 and M6-L ADR L4-5 with Nick Boeree, UK - forever grateful to you Nick! Still doing great.
Prior to the fix: Severe DDD L4-5 and L5-S1 with moderate facet degen at L5-S1, but only mild facet degeneration at L4-5.
http://healthyback2011.blogspot.com/
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