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  #31  
Old 07-29-2009, 02:27 PM
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Thumbs up "Laurie Live!"

Laurie Todd, the Insurance Warrior, is going to be on live radio tomorrow (Thursday) morning. That's July 30, from 8:00-8:30 a.m., Pacific Time.

Anybody anywhere can listen to me live on the station's website:

www.chatwithwomen.com/pages/live.php

Or, if you live in the Seattle area, you can listen at KKNW 1150AM.

*********
All health insurance is good, until you need something that they do not want to pay for.

As insurance premiums skyrocket (mine just went up 17%), and the medical care that they cover plummets, more and more of us will find ourselves facing an insurer who doesn't want to pay.

Treatments are denied with words, and denials are overturned with words. I have figured out how to turn insurance words to our advantage.

I invite you to share this with everyone you know who has health insurance.


Laurie Todd
www.theinsurancewarrior.com
__________________
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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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Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
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  #32  
Old 08-30-2009, 03:11 PM
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Exclamation

The Insurance Intelligencer
8/31/09

The $3.7 Million Man

As I go forth to speak to general audiences, people make remarks about the state of healthcare.

I heard this one last week in the farm belt of Ohio:

"The problem with healthcare these days is greedy doctors."

Treatment denied

On August 5, I received a call from Tina in Michigan. Her husband Michael had been diagnosed with metastasized abdominal cancer. He needed the same tried, proven lifesaving surgery that I had undergone four years ago.

The facts of the case:
  • The surgery was denied because it was "out of network."
  • Tina has a self-funded plan. This means that her employer gets to approve or deny Michael's treatment.
  • The employer is St. John Health. which is a non-profit Catholic hospital.
  • The insurer is Blue Cross Blue Shield of Michigan, which is also a non-profit.
After the treatment was denied in June, Tina and Michael left the appeal to their doctor. He wrote a one-page letter which said, "I am the treating physician. This is the patient. In my professional opinion, the patient needs this treatment."

The doctor's appeal was denied. A second letter was on the way to the employer/insurer, to launch a second appeal. When Tina called me, the employer's position was: "We won't consider this second appeal until August 24, because the Regional Appeals Committee doesn't meet until then."

Michael's surgery was scheduled for August 20.

I said, "Stop that second appeal. With a self-funded plan, you only get two appeals. After that, it's the Federal District court for you -- good luck with that. Stop the presses, we are going to write a proper appeal."

How much does the CEO make?

When I take on a case, the first thing that I do is to find the highest-level executives of the insurance company -- and of the employer, if it is a self-funded plan. Names are power, access is power, personal contact information is power.

I found the top executive at St. John Health, the Catholic non-profit hospital. In the process, I discovered that there is a higher authority. I am not referring to a divine power, but to Ascension Health Ministries. The mission of Ascension Health Ministries: "We commit ourselves to serving all persons, with special attention to those who are poor and vulnerable." The highest-level executive at Ascension Health Ministries is Anthony Tersigni. Last year, Anthony Tersigni earned $3.7 million. Ascension Health Ministries closed three of their less-profitable hospitals in inner-city Detroit during 2008.

The motto of Ascension Health Ministries? "Healthcare that leaves no one behind." Tina Beitel has worked for St. John Health for nineteen years. They must have missed someone, because they were about to leave her husband behind -- by denying the only treatment that could save his life. Next, I went looking for the head of Blue Cross Blue Shield of Michigan. Blue Cross Blue Shield of Michigan is also a non-profit.

BC/BS of Michigan raised their group rates this year by 22%. They applied to raise the rates on individual policies by 56%. The president of BC/BS of Michigan is Daniel J. Loepp. His total compensation last year was $2.9 million.

In the process or writing and winning forty-four lifesaving appeals, I have developed a high appreciation for the absurd. However ... the irony of this one made my teeth ache.

My goal was to sit here in Seattle, in my worn-out pajamas, and to craft a document that would have Anthony Tersigni running for his checkbook.

How much does the doctor make

The doctor in this case is the surgeon who brought me back from the brink of death four years ago; his name is Dr. Paul Sugarbaker. He has performed over 1500 of these twelve-, fifteen-, twenty-hour surgeries. He has published over seven hundred medical journal articles documenting every aspect of this treatment -- including his outcomes -- over a period of twenty-nine years.

Dr. Sugarbaker pioneered the surgical techniques whereby the surgeon removes every bit of tumor down to 2.5 mm. Then, he treats the remaining microscopic cells with heated intraperitoneal chemotherapy for two hours, making sure that every surface is contacted.

I had metastasized appendix cancer. This same treatment could achieve exponentially better outcomes for people with colon cancer and ovarian cancer. People often ask, "Why aren't more surgeons learning how to do this? Why don't more surgeons want to do this, if it saves more lives?" Why? Insurers hate to pay for it. Hospitals do not like to book such long surgeries, because four five-hour surgeries are more profitable than one twenty-hour surgery. Besides, who would want to work that hard? A surgeon who performs twenty-hour surgeries for thirty years will eventually look like Dr. Sugarbaker -- stooped, with a visible "widow's hump," and permanently listing to one side.

A surgery of such magnitude requires a long hospital stay, with expensive post-operative care. The only thing to be gained from it is better outcomes for patients.

Dr. Sugarbaker is either at the hospital, or out teaching and demonstrating surgical techniques -- all week, every week, sixty hours a week. He rides a bike to work, he has a small office in the doctor's office building, his minimal staff work tirelessly to get insurance companies to pay for this treatment.

How much does Dr. Sugarbaker charge for performing this grueling surgery? $25,000.

And, even when insurers do grudgingly agree to pay for it, they have many ways of reducing reimbursement after the fact. Although Dr. Sugarbaker may bill $25,000, he never actually receives $25,000. Believe it or not, there are bean-counters in an insurance company office who review the surgeon's bill, crossing off line items as "not necessary." When the deleting and bundling of codes is done, he has received as little as $400 for one of these surgeries.

Who would want such a life?

********

Anthony Tersigni, $3.9 million. This equals one-hundred fify-six grueling twenty-hour surgeries, at $25,000 per life saved.

I have never been so motivated to win an appeal. As I researched and wrote, I would say to Tina, "Wait till Mr. Moneybags gets a load of THIS." It took me three days to craft my War Documents. After I faxed and emailed it to all of the top executives in the middle of the night, Tina worked the phones, "Did you receive my urgent, expedited appeal?" Eight days after Tina and I first spoke, the denial was overturned, and the treatment for Michael was approved. That was August 13. They flew to Washington, D.C. on 8/17, and Michael had his surgery on 8/20. Gee, I guess that they really didn't have to wait until 8/24 for the Regional Appeals Committee to meet.

Which brings us back to where we started. Greedy doctors?

If this is all about greed, we will soon have many insurance company CEOs, and no surgeons to save our lives.

Peaceful Insurance Warrior-ing,

Laurie Todd
__________________
"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
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  #33  
Old 08-30-2009, 11:19 PM
2cool4U 2cool4U is offline
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Default Greedy doctors, indeed.

Excellent article. Last time I checked, physician incomes accounted for about 14% of the total health care spending. That's right, 14%. The rest? Hospitals, insurance companies, home-health care companies...the list goes on. If you cut physician pay by 50%, you would save 7% of the total spending. The savings would be substantial, but there would be no doctors left in practice!

I don't want to reveal my exact costs, and I actually don't know the real final number that my insurance company paid after negotiations, but my surgeon was, in my opinion, woefully under-reimbursed for the 3-hr. surgery and 3 days of post-op visits. And, no, I did not get any professional courtesy discounts. I checked to make sure. In my case, all of the physicians compensation combined accounted for less than 10% of the total cost of the surgery.

That's an astounding number to me.

-tc-
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  #34  
Old 09-21-2009, 10:56 AM
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Default The Insurance Intelligencer

9/20/09

The Case of Little Nicholas

With healthcare reform in the news, I see the term "standard treatments" bandied about. Such-and-such a plan will cover standard treatments. As though there were such a thing.

Many of you have seen me unmask insurance company words:

Experimental = It's out-of-network, and we don't want to pay for it.

Not medically necessary = It's out-of-network, and we don't want to pay for it.
Not a covered benefit = It's out-of-network, and we don't want to pay for it.

Rarely are in-network treatments denied as experimental, not medically necessary, or "non-standard." Insurers do not deny treatments based on clinical benefit, geography, or even cost. It's simply a matter of in-network vs. out-of-network.

I have dug deeply into the rationales (scientific reasons) that insurers offer to support such denials. There is nothing there. No science. No clinical evidence for the treatments they do pay for, and no lack of clinical evidence for the treatments they don't pay for.

"Standard treatments" fall into the same Bermuda Triangle as all other insurance company words:

Standard treatments = It's in-network, and thus we pay for it.

Which brings me to the story of little Nicholas ...


Nicholas needs major surgery on his skull

I am often asked, "How do people find you?" Short answer -- in the most amazing ways.

Two weeks ago, I received an email from Heather in Michigan. Heather's six-month-old son, Nicholas, needed surgery on his skull, and her insurer had denied the out-of-network surgeon. One of the mothers in her online support group told her about me. Heather ordered my CD ("The Sample Appeal"), and wrote an appeal herself. That appeal was also denied.

Heather received last month's newsletter, "The $3.7 million man." The insurer in that case was Blue Cross Blue Shield of Michigan. She thought, "That is my insurer. Maybe Laurie will help me." The planets align, and then people are brave and bold enough to reach out to me.

Nicholas had a malformation of the skull called "synostosis." The different parts of the skull are joined together by bands of fibrous connective tissue called "sutures." When babies are born, these sutures are relatively loose and open. The suture lines fuse gradually, as the baby grows. This is an elegant system -- designed to protect the brain, while also allowing it to expand in just the right places.

In approximately one out of every three thousand babies, one or more of the sutures of the skull fuse prematurely. The skull immediately begins to assume an abnormal shape. Pressure on the brain can bring all manner of scary possibilities such as vision problems, seizures, and developmental delays.

In order to fix cranial synostosis, the skull has to be removed, reconstructed, and put back together. With just enough "give" in the right places to allow for unobstructed growth of the brain. This surgery is as complex as it sounds. It is also fraught with danger -- the most common surgical complication being massive bleeding.

A cranial reconstruction by a top-notch surgeon is a work of art.

The insurer wants to keep Nicholas in-network

I asked Heather a few questions about the medical story, and studied her two denial letters. I looked at the qualifications of her surgeon-of-choice. Nicholas' surgery with Dr. Fearon in Dallas was scheduled in ten days.

"The insurance company doesn't want you to go to Dr. Fearon. What do they want you to do?" I asked.

Heather explained to me that her HMO -- Blue Care Network -- wanted them to choose an in-network surgeon for this complex cranial surgery that would determine the quality of the rest of his life.

One of the in-network surgeons proposed an endoscopic "cranial stripping" surgery. The other wanted to completely dismantle Nicholas' entire skull, even though his defect only affected the back of his head. The second surgeon scoffed at the first one, saying, "That technique is way out of date. We haven't done cranial stripping for ten years ... poor outcomes."

In their first denial, Blue Care Network suggested that they look to Nicholas' primary care provider for guidance. The PCP's guidance consisted of, "I don't know anything about either procedure."

In their second denial, BCN came up with three more in-network surgeons, and instructed Heather and her husband to make an appointment with one of them. Time was flying. By this time, Nicholas was six months old -- the outside limit of optimum age to have this surgery.

Two of the second surgeons were cleft-palate experts. The third facility on BCN's recommended list had no pediatric plastic surgeon on staff.

The appeal

I said to Heather, "I will take this case. However, you are going to need to get down in the trenches with me. I know nothing about this condition, nothing about this surgery. I have no proof in my files, and I have no cases of precedent. You are going to have to get me the information that I ask for, call the insurance company and say what I tell you to say. Can you do that?"

Over the next six days, I witnessed the blazing determination of a mother, fighting for her baby.

As for myself, I spent the next three days in my famous worn-out pajamas. I digested scientific articles, websites, book chapters. Then I wrote. Thirty-four pages of persuasive expository prose.

Heather became quite the sleuth -- pressing her case, talking to Medical Directors, finding out what she could about the progress of our appeal. At a certain point, she said, "Isn't this fun?"

I said, "Do you realize that, when you called me three days ago, you said that you were desperate? Now we are having fun, fighting tooth and nail for this surgery."

This is so not about insurance. It is about bringing people through the fire, with spirits up, dignity intact, and sense of humor in full swing.


The best of all possible worlds

Four days after receiving my 34-page appeal document, Blue Care Network decided to pay it all. Never was there more joy at winning an appeal.

The approval came on Thursday, and the family flew to Dallas on Sunday. Little Nicholas had his surgery on Tuesday morning -- a complete success. He is already back in Michigan, sleeping in his own crib.

********

Which brings us back to where we started: Standard treatments. "Standard" is a synonym for "in-network." Babies with synostosis are sent to in-network surgeons who specialize in breast reconstruction, cleft palates, and so on. Some never get to see a pediatric plastic surgeon at all. This would be your standard care. If the surgeon is in-network, he is standard, and he will do.

In writing appeals for all sorts of diseases and conditions, I have learned that there are always one or two physicians who are getting better outcomes. They are often physician-scientists -- publishing many scientific articles, inventing surgical tools, constantly studying, publishing, and improving their outcomes.

They are not likely to be in-network for your insurance. Many of the true pioneers have dropped most of their insurance contracts. Why? The don't need the headaches, and they are weary of the pitiful reimbursement. They are too busy saving lives.

This is your six-month-old son. Is "standard" good enough for you?

Happy and peaceful Insurance Warrior-ing,

Laurie Todd
http://www.theinsurancewarrior.com/
__________________
"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
  #35  
Old 10-18-2009, 07:11 PM
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Exclamation The Insurance Intelligencer October 18, 2009

No Happy Dance for Elizabeth

This week, I lost an appeal. I want you to know who defeated the mighty Insurance Warrior, so that you can run like the wind from this indomitable beast.

The Insurance Warrior was defeated by ... drum roll please ... a self-funded plan.

********

For years, I have been warning you about self-funded plans. Do you even know if you have one? If you work for a large company -- chances are that you do.

In a self-funded plan, YOU HAVE NO INSURANCE. How is this possible? In a self-funded plan -- regardless of what coverage the plan documents say you have -- your employer has sole and absolute power to over-ride the insurance company, and interpret the plan as they see fit.

Your employer is not an insurance company. Therefore, if you are covered by a self-funded plan ... you cannot speak to the Insurance Commissioner, and you are not protected by state insurance law. Let's say that your state has certain minimum requirements for health care: Insurers have to provide mammograms, a certain level of prenatal care, etc.

Your self-funded plan does not have to do anything. State rules and regulations do not apply. In a self-funded plan, your insurer is free to provide sub-standard care as defined by state law -- because your employer is not an insurance company.

"But I HAVE an insurance company, " You say, "It is self-funded, and the insurer is Acme Blue Cross Blue Shield." Joke's on you. The minute that a health insurer enters into a self-funded plan, it instantly becomes "not-an-insurance-company." Your Acme BC/BS is now, magically, a "third-party administrator."

Instead of being governed by state law, self-funded plans fall under ERISA. That would be federal law, good luck appealing to them. ERISA was designed to regulate employee pension plans. Sneaking self-funded plans into ERISA was the world's biggest gift to health insurers.

Take your employer to court?


In your self-funded plan ... there is no insurance company. You have no insurance. All you are left with is the whim of your employer. After your employer denies your treatment, your only option is to hire an attorney, and take your employer to court. There are, however, major disincentives to doing so:
  • Do you really want to fight your employer in court, after spending a year fighting cancer? Most people will never take their employer to court. Employers and insurers know this.
  • In an ERISA case, the court is not allowed to award damages. If you win your case, all you get is payment for the treatment that they should have paid for to begin with.
  • In an ERISA case, the court is not allowed to let you recover attorney's fees. You will have to pay them, even if you win.
Sound like the deck is completely stacked against you in a self-funded plan? It is.

I have heard of two cases where the employer denied because, "You have a higher salary than most of our managers. If we pay for your cancer surgery, the other employees would be jealous."

They can say whatever they want, they can deny for any reason they choose. You have no protection, you have no recourse, there is nothing you can do about it. It is a self-funded plan.

Elizabeth's employer spits in my eye

Last week, I fought a fierce appeal for Elizabeth from Boston. She needed the same lifesaving surgery that I received four years ago. Her surgery is scheduled for October 20.

It is a self-funded plan: Philips Healthcare is the employeer, with Empire Blue Cross Blue Shield as the "insurer."

I deployed my usual strategies, and prepared and delivered my usual masterpiece of persuasive expository prose. In response to my appeal document, the president/CEO of Empire BC/BS contacted Elizabeth personally, and hooked her up with a decision-maker who could move her case along.

By Thursday afternoon, Empire BC/BS had approved the treatment. They promised to have a single-case contract ready for signature and on Dr. Sugarbaker's desk by 4:00 p.m.

At 2:00 p.m. on Thursday, Philips intervened. They said, in effect, "We don't care if the insurer approved. We aren't paying."

Yes, they can do that. And so can your employer. Pay heed to the fine print in your plan documents:
Philips, as the Plan Administrator, shall have the exclusive right, power, and authority, in its sole and absolute discretion, to administer, apply and interpret the plan and any other plan documents and to decide all matters arising in connection with the operation or administration of the plan.
Sound like your employer has divine power over your life and death? They do. Run, run like the wind from self-funded plans.

********
Happy and peaceful Insurance Warrior-ing,

Laurie Todd

http://www.theinsurancewarrior.com/

Know anyone who is fighting an appeal? Steer them to my new CD, The Sample Appeal.

www.theinsurancewarrior.com/thebookandthecd.html
__________________
"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
  #36  
Old 10-18-2009, 11:13 PM
2cool4U 2cool4U is offline
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Default Except your employer may have no other option

Unfortunate situation. However, how does an employee "run like the wind from self-funded plans?" It's not like an employee typically has several options of health care plans to choose from. And small businesses with high employee health care costs may not be able to choose other plans to offer to their employees. In the latter, the small business owner is saddled with a high deductible for each employee, and the owner has to pay if there is an illness. That deductible can run $10-20K per employee per year. The costs can be staggering if only a few employees (or covered family members) develop chronic illnesses. Those same costs then result in the employer being unable to secure a different health insurance plan for the business.

Once again, unfortunate, but does the author suggest that people turn down jobs in this economy if the potential employer has a self-funded insurance plan? Or is there a suggested course of action here that would lead to action on the part of our lawmakers that I missed?

-tc-
__________________
L5-S1 rupture 11/04, left leg pain for 2 wks
Regular exercise/pain-free until 2007
L5-S1 degen. disease w/constant pain since 6/07
PT, ESI, SI jt injections, 3-level nerve root inj. x 2
Massage, heat, ice, TENS, etc
L5-S1 Charite Jan. 19th, 2009, very happy w/decision
New back pain in upper back though.
  #37  
Old 12-28-2009, 08:54 PM
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Angry The Insurance Intelligencer

Well, copyright infringement seems to be a common theme tonight! Any way, Laurie's column is below...thanks Laurie!
___________________________________________

The Insurance Intelligencer
12/28/09
The Biologist and the Plagiarist

Steve is a fish biologist from Eastern Washington. This month, we fought the appeal for Steve's wife Maria -- through two levels of internal appeal, two independent reviews, and one in-person hearing. Because of Steve's scientific curiosity, lies were revealed, illusions dispelled, and a plagiarist unmasked.

The good news? We won.

When I heard that there was a couple in Eastern Washington who needed to get to Dr. Sugarbaker -- and had Premera Blue Cross Blue Shield -- I thought, "Piece of cake." In 2007, I had already won that battle for Norma. I wrote a big mean letter to Premera, and Norma's husband Kim exploited his business connections, and called the medical director. Within twenty-four hours, we had approval. What could be easier?

Never underestimate your opponent.

The written appeal

Am I getting too good at writing appeals? Up until a few months ago, insurers received my appeal documents, and either approved or denied the treatments. All of a sudden, insurers are finding ways NOT to decide.

On receiving my appeal for Maria, Premera immediately sent it to an "independent review organization." This was not the next step according to their appeals process. I believe that the appeal was such a hot potato -- so embarassing to Premera -- that they did not want to uphold their denial, and they did not want to be responsible for reversing their denial. So, they sent it out to independent review.

The independent review

"Independent review" sounds like a good thing. It sounds like due process, taken out of the hands of the insurance company, yes? An "independent review organization" sounds very official -- like an institution. Surely an independent review org has many many experts on staff? They are qualified, regulated, diligent and impartial? How I wish that they were.

The independent review came into being in response to patients who were denied treatments by their insurance companies. These patients were also voters, and they put pressure on their elected officials, saying, "The businesses that will have to pay for our treatments gets to decide whether they are 'medically necessary' or not. This is wrong, it is the world's worst conflict of interest."

Independent review orgs sprung up like mushrooms, and state insurance commissioners and insurance companies added a new layer to their appeals process -- independent review. I assume that this development quieted the clamor to remove medical decisions from the hands of insurance companies.

When we are ill, and are denied the one treatment that could save us -- we want desperately to believe that there is some powerful entity that will step in and help us. This is a dangerous -- sometimes fatal -- belief.

More and more, insurers and employers (in the case of self-funded plans) hand medical necessity decisions off to independent review orgs. Who are these organizations, who hold your life in their hands?

Independent review organizations are not licensed. Some states require them to have "clinical peer" reviewers, some don't. They are not accountable for their decisions. An independent review org could uphold 100% of the denials sent to them, and nobody would ever know. Often, they are the end of the line for you; there is no more due process after the independent review.

Guess what? In some states, the insurance company doesn't have to abide by the decision of the independent reviewer. In these states, why do they bother to do them? Talk about your illusion of due process.

Like insurance companies, independent review orgs understand the power of words. They dream up power names like "Maximus." ("We will crush you like a bug!") Or quasi-medical names like "Medical Review Institute" (MRI).

The first time that one of my cases got sent to independent review, my helpee was thrilled, "They are independent ... that's got to be good, right?" "Hold your horses," I replied, "Let me find out who these people are."

The requested treatment was cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for appendix cancer with peritoneal spread. The independent review org was a chiropractor in Texas with a post office box.

The plagiarist

Premera was so razzle-dazzled by our appeal that they prematurely sent it out independent review. The reviewer -- a breast cancer doctor -- upheld the denial.

Steve and I found the denial letter very strange. It didn't mention any of the insurer's stated reasons for denial, and it didn't address any of the points that we had approved in our written appeal.

The last page of the reviewer's letter mentioned an obscure article which Steve had never seen before. Because of his scientific curiosity, he googled the article.

This article appeared in only one place -- a blog called "Cancer Treatments." This blog lists hundreds of different cancer treatments, and gives a generic paragraph or to to introduce them to laymen.

The verbiage sounded familiar to Steve. Pages two and three of the reviewer's three-page decision were plagiarized directly, word-for-word, from the blog post about cytoreductive surgery. The entire post was cut and pasted into the reviewer's letter.

Some expert. Some review.

The hearing

After the sham independent review -- and five days before Maria's surgery date -- Premera ordered my helpees to drive over the snowy Cascade mountain range, to present our case once again, at Premera headquarters, at an in-person hearing. I wrote a speech for Steve, and a speech for me.

Our presentations must have been powerful. Once again, Premera denied, and handed off the case to another independent review organization.

This time, I insisted that the reviewer have relevant clinical experience, and that the reviewer receive and consider every page of information that we had prepared -- including both of our speeches.

Within a few days, the denial was reversed, the treatment was approved, and Steve and Maria were on their way across the country for her lifesaving surgery.

Disclaimer: I am not saying that no insurance denial is ever overturned on independent review. I am simply saying not to count on it. Know that an independent reviewer is not necessarily qualified to render an opinion on your treatment, and may not even bother to learn about it. They may, they may not. In other words, do all you can to win your appeal -- before it ever gets to the Bermuda Triangle that is independent review.

******

Maria had her surgery on December 16. Dr. Sugarbaker was able to remove all of the cancer, and to perform the heated intraperitoneal chemotherapy. A good outcome, and a promising future for Maria. Now she builds her strength, walking to the patient lounge, and watching the snow fall peacefully in Washington, D.C.

A little bird has told me that another patient from my area needs to get to Dr. Sugarbaker. Guess who is her insurer? Premera Blue Cross Blue Shield. Here we go again.

Looking forward to my Class of 2010,

Laurie Todd
http://www.theinsurancewarrior.com/
__________________
"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
  #38  
Old 01-25-2010, 07:26 PM
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Default The Insurance Intelligencer - Jan 25th, 2010


Max's Head

Remember six-month-old Nicholas, who had his skull fixed by Dr. Fearon? It wasn't long before Nicholas from Michigan led to Max from California.

While we were fighting Max's appeal last week, his mom Cassie was wrangling a two-and-a-half year old, and a six-month-old who doesn't sleep. They live in Southern California. Torrential rains were falling, and the power was going on and off.

Our opponent was Anthem Blue Cross of California -- the biggest, baddest, most loaded-for-bear insurance company in the entire country. The last time I faced off with Anthem, they won.

Will the house wash away? Will Laurie be defeated by the Goliath of health insurance? Will Cassie tear off all of her clothes, and run screaming into the street?

What is this surgery, anyhow?

When babies are born, the many sutures that connect the parts of the skull are soft and pliable. They fuse gradually, to allow the brain to grow in just the right directions. In babies with craniosynostosis, one or more of the sutures fuses prematurely. The head immediately takes on an unusual shape.

In order to fix this condition, the skull is taken apart and expertly refashioned, with just the right amount of space left for the brain to grow. The problem is that the surgeon who gets the best outcomes with this surgery is in Dallas, Texas, and he is not contracted with Blue Cross Blue Shield.

With insurance companies, there is a tremendous push to keep us in-network and local -- regardless of the qualifications or expertise of the local in-network surgeons.

Anthem sent Cassie to some fine, fancy, distinguished neurosurgeons in Los Angeles. She was very comfortable with them. The only reason why she decided to fight to get to Dr. Fearon was because the local surgeons all told her that catastrophic bleeding is a common complication of this surgery, and Max would definitely need a transfusion. Dr. Fearon has made innovations that drastically reduce the rate of transfusion.

It was the transfusion that bothered her. Little did she know that it was the type of surgery that the local surgeons were offering that should have given her pause.

The Pi-procedure

I had Cassie write Max's medical story. Then, I questioned her, "What did the surgeons tell you about the surgery that they would do for Max? How did they describe it? What did they say?" I need to know what the in-network doctors are offering, so that I can contrast it with the elegant posterior cranial vault remodeling performed by Dr. Fearon.

Try as I might, I could not figure out what they were doing. It was all very murky and vague. What was this surgery being performed in Los Angeles?

I was able to find an article by a nurse at Children's Hospital in Los Angeles, describing the surgery that they do there. I still couldn't figure it out. How was I ever going to make this clear to Anthem?

Finally, I sent the article to Dr. Fearon, who replied, "This article describes a type of strip craniectomy called the Pi-procedure."

Ah, the Pi-procedure! It is not the same as what Dr. Fearon does. The skull remodeling is so simple that a neurosurgeon often performs it without the assistance of a cranio-facial surgeon. The doctor cuts out the fused suture, and discards that part of the skull. He then cuts out two strips next to it, and joins the whole business together with plates and screws.

I crafted the thirty-four-page appeal, complete with diagrams, and sent it to Cassie. She called me, "I had no idea."

"They didn't explain it to you, did they?" I replied.

We have a dream

When people lose an appeal, I counsel them to do things differently the next time. Last time, when I lost to Anthem, I came out with all guns blazing. This time, I held back a little bit. I decided that, with Anthem being so big and powerful -- if I came out swinging, they would hit me upside the head with a 2 x 4.

So, I softened my approach. There were no titles like, "Anthem BC of CA violates state law such-and-such." I stated all of the powerful facts. However, I also gave Anthem a degree or two of slack, to leave a little room for compassion to rush in and fill the vacuum.

I deployed the appeal copies by fax and email on Sunday night, as usual. I forgot that Monday was Martin Luther King day.

The compassionate Buddhas must have been watching, because the holiday turned to our advantage. One of the many executives to whom I addressed the appeal was working on Monday. High-level executives at insurance companies are instructed never to read appeals, of course. I make them as irresistable as possible, to overcome that obstacle.

Our executive sent me a very respectful reply on Monday evening, and told me that he would handle it. (These higher-ups often think that I am the insured person, because the email or fax comes from me.) I believed him.

The next day, Cassie heard from Anthem -- "We're working on it." On Thursday, the surgery with Dr. Fearon was approved.

Cassie did not run screaming into the street, the house didn't wash away, and Laurie had her sweet victory.

Best of all, little Max will have his surgery.



Happy and peaceful Insurance Warrior-ing,
Laurie Todd
www.theinsurancewarrior.com


__________________
"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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  #39  
Old 03-04-2010, 05:25 PM
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Default Insurance Intelligencer 3/2/10

The Emperor Has No Clothes

A woman in Minnesota sent me a copy of her appeal. She had followed all of the suggestions in my CD. She did the research, performed her due diligence, proved her points.

When I read this appeal, I knew that it wouldn't fly. She sounded too much like an eager student, hoping for an "A." It was earnest, not intimidating.

An illusion of due process

In order to face off against an insurer, and win the battle on their home ground -- we need to bear in mind that the appeals process is not meant to lead to an approval.

Appeal levels, peer reviews, hearings, committees, independent reviews -- none are meant to lead to an approval. If we believe that we will get unbiased consideration at any of these levels, we miss the poiint, we charge up the wrong hill, we are barking up the wrong tree.

Disclaimer: I am not saying that no medical director ever considered a treatment in good faith, based on whether or not it was safe and effective. I've just never seen it happen.

How can I tell that this system of appeals and grievances is a stacked deck? Let me count the ways ...

The telephone game

You are allowed access only to people with no decision-making power -- customer service reps and case managers. This phone interation is not meant to bring you any closer to an approval.

What is the job of a customer service rep? To tell you to wait for a letter. What is the job of a case manager? To tell you to wait for a letter.

First and second level reviews

A treatment is "medically necessary," if the medical director of the insurance company says it is. It is "experimental," if the medical director of the insurance company says it is.

In all of my fifty-seven cases -- the medical director knew nothing about the treatment under review, and he was not qualified to render an opinion on the treatment. The majority of these medical directors are "family practice physicians." It must be slow times in the "family practice" business, since so many of them have resorted to working for insurance companies.

My favorite unqualified medical director had denied reconstructive skull surgery for one of my infant helpees. He was a psychiatrist. We joked, "Hey, I guess they figured head/skull, same geographical location ..." At a certain point, I said to her, "The next time you call that medical director, tell him that these denials are driving us CRAZY, and we need a session!" He knew nothing about skull surgery, nor did he care to learn about it.

I have never seen an insurance company reverse a decision from first- to second-level review. Unless, of course, they received a powerful appeal from the patient in the interim. One medical director will not rule differently than another; they both work for the same insurance company.

Medical policy statements

Med policies are a body of hundreds of official-looking documents. Every insurer has them. They give the scientific reasons why the insurer isn't going to pay for your treatment. No matter what your coverage is, they aren't going to pay for it.

Medical policies were instituted in the 1990s in response to a hue and cry from outraged insured people. They had figured out that insurers could pretty much call any treatment "experimental" or "not medically necessary" -- with little or no justification.

Med policies are supposed to hold insurers to some kind of scientific standard. Guess who writes them? Insurance companies.

If you don't believe that medical policy statements are sham documents -- consider the Tale of the Two Medical Policies.

I decided to find and print all of the medical policy statements that I could find for hyperthermic intraperitoneal chemotherapy (HIPEC) -- the treatment that I had in 2005, and for which I have written many appeals.

The med policy from Blue Cross Blue Shield of Massachusetts started looking familiar. It declared HIPEC to be "medically necessary," and cited twenty-nine medical articles and other sources. I pulled out the Premera Blue Cross medical policy, which deems this treatment to be "experimental." Both med policies used the same twenty-nine articles to prove that HIPEC was both experimental, and not experimental.

These documents are not designed to hold insurers to any standard. They are meant to look official, with the expectation that nobody but me will ever challenge them.

Peer reviews

The peer review is where the same medical director who denied the treatment the first time calls your doctor, and tells them why they aren't going to pay for it. This medical director is a family practice physician. He is not a surgeon, a cancer expert, or any other type of "peer." He is not a peer, and it is not a review.

Independent reviews

People get pretty excited, when they lose a few appeal levels and their case goes to independent review. They say, "It's independent, that's got to be good, right?"

Like med policies, independent reviews came into being because people got fed up with insurers denying whatever they wanted to deny, with no checks and balances. Only problem? There are no checks and balances on independent review orgs.

Independent review organizations are not licensed or regulated. They are not required to employ "medical experts." In many states, they are not held to any standard at all. I delved into an independent review org that was about to rule on one of my cases -- it consisted of a chiropractor in Texas with a post office box.

Independent review orgs are not accessible, and they are not accountable. They could uphold every denial that came their way, and nobody would ever be the wiser.

Word to the wise: If you want to make the most of this illusion of due process, at least put a powerful appeal in front of these review org people. Even if they know nothing, and aren't required to do anything -- that chiropractor in Texas might be impressed enough to reverse your denial.

In order to win our appeals, we need to know our opponent, and stay focused on the big picture. The only due process that we can expect from our insurance companies is the due process that we create ourselves.

Listen to my new audio spot:
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*******

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__________________
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  #40  
Old 06-28-2010, 02:35 PM
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Harrison Harrison is offline
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Exclamation The Law of Unintended Consequences -- or Intended?

The Insurance Intelligencer
6/28/10

The New Healthcare Law: Protection, or Pretense?

The media hoopla over the health care bill is over; the bill has been passed. As of 3/23/10, the Patient Protection and Affordable Care Act of 2010 (PPACA) is the law of the land. May we assume that the inequities, cruelties, and brutal realities of private health insurance are now tempered, improved, resolved?

Legions of healthcare lawyers are currently poring over the PPACA. I am just one cancer survivor -- one who has won fifty-nine major insurance appeals for others by understanding the real reasons for insurance denials, and what it is that motivates insurers to reverse those denials.

I would like to share a few provisions of the law that stood out for me, given my experience with how insurance company policies, provisions, and decisions play out in the real lives of patients, and the dedicated medical providers who treat us.

Grandfathering

Grandfathering = the mother of all loopholes, right off the top. Which insurance plans will be exempted from the new law? All insurance plans in existence on the date the law was passed. All of them.

There are a few provisions of the new law that do apply to existing group plans: health insurance for employees working thirty hours or more, dependent coverage for children up to age twenty-six, various restrictions on denials for pre-existing conditions.

However, the bottom line is that all existing insurance plans are exempt from most of the provisions of the new law. They can continue to operate as they always have, they can enroll new members. Business as usual.

Disclosure

There are all manner of complicated disclosure requirements for insurers offering new plans. Just one problem with this -- insurers have had fifty years to perfect the art of "concealing, while appearing to disclose."

Good luck getting insurance companies to disclose.

Example #1: Let's say that insurers are required to disclose their number of treatment denials. My lifesaving surgery was denied in 2005; I have the denial letter in my files. However, as far as my insurer is concerned, there was no denial. In their records, the entire episode is classified as a "goodwill payment."

Example #2: Under the new law, insurers offering new policies will need to disclose their "claims payment policies and practices."

I could write a dissertation on how health insurers reduce reimbursement, after the medical treatment has been performed. Bundling codes, changing codes, deleting codes -- the variations are endless. Some insurers even go retroactive -- digging into past cases, looking for ways to take away even more payment.

However, the biggest, most secret, most baffling practice to patients is the infamous "reasonable and customary." All of the disclosure requirements in the world will not unmask nor demystify this massive illusion of coverage.

Let's say that the patient has a PPO. Their benefits booklet states that the insurer will pay "80% for out-of-network treatment." The truth, but not the whole truth. Every patient who has ever contacted me -- regardless of their level of education or sophistication -- believes that the insurer will be 80% of billed charges. Patients embark on astronomically expensive surgeries and hospitalizations, believing that 80% of their bills will be paid.

Far from it. The insurer will pay 80% of whatever the insurer deems to be "reasonable and customary." If you call your insurer, and ask, "What does reasonable and customary mean?" -- they will reply, "We do extensive research and surveys, all over the country, to see what medical providers are charging."

There is no research, and there are no surveys. The numbers upon which insurers base their reimbursement are secret, mysterious, and constantly changing.

Guess where insurers get these figures? Ingenix. Guess who owns Ingenix? United Healthcare.

In 2008, New York attorney general Andrew Cuomo took sixteen major insurers to task for this misleading-to-fraudulent practice. Ingenix was fined $300 million, plus $50 million to set up a non-profit database to generate the numbers on which reimbursement will be based. How fair and impartial this new set-up will be remains to be seen, as the first of the sixteen insurers just settled with Cuomo this January.

When we require insurers to disclose their reimbursement practices, they will simply say, "Our reimbursement is based on reasonable and customary charges."

Very few consumers will ever ask, "What do you mean by that?"

External review

64% of the employees in this country are insured by self-funded plans. People, this means that your employer -- who knows nothing about the practice of medicine -- has absolute power over your life and death.

The only check on this divine right is the federal district courts. Good luck with that, when surgery is scheduled for next week.

The new healthcare law requires that self-funded plans submit their denials to "external review." What is external review, and is it up to this herculean task?

Independent/external review processes came into being in the 1980s, because many people got fed up with insurers and employers having sole decision-making power over medical treatments. People thought, "It's independent, it's got to be better, right?"

In early 2009, a woman called me from Colorado. She had exhausted all of her internal appeals with the insurer; she was on her way to independent review. I said, "Hold your horses. Who are these people?" The case under review involved a massively complex abdominal surgery for cancer, with heated intraperitoneal chemotherapy.

It took me twenty minutes to discover that the "independent review organization" was a chiropractor with a post office box in Texas. It was not an organization, and it was not qualified to perform a review.

This external/independent review process is anonymous, unregulated, unsupervised, and accountable to nobody. They could uphold every denial that came their way, and nobody would ever know.

Is this not a fragile branch upon which to balance the lives of 64% of the employees in the United States?

******

Just a few thoughts about the new healthcare law. I will constantly be looking for ways in which I can use it to help you, when your treatment is denied.

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
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