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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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Old 11-26-2007, 07:53 AM
AZFamilyGuy AZFamilyGuy is offline
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Join Date: Jul 2007
Posts: 7

Hi all,

1st time poster here, but I've poured over this board for hours upon hours and without even having spoken to any of you or replied in any of your threads, I feel like I know a lot of you.

I'm posting in this thread to let you all know that I spoke with Laurie Todd yesterday - she was in AZ and setup an impromptu talk at a wine bar here in AZ. I was one of two people that showed up so I got a LOT of face time with her - it was awesome! I bought a copy of her book (haven't had time to read through all of it yet) and I'm assuming most of what she told me is in there already, but here are a few of the notes on writing insurance appeals that I took while talking to her (she told me to feel free to share it in my own words with everybody on the msg board):

- Make your appeal look like a professional report (i.e. title page, TOC, cover, etc.). Laurie mentioned that every appeal that she's heard of that was more of an appeal letter than a report has failed.
- Get precedent cases (people that have had their insurance pay in the past for your same operation)
* Get as much info as they'll willingly share with you (name, date(s) of surgery, costs (broken down into hospital, drugs, repeat surgeries, etc.) if possible)
* See this thread for a list of available precedent info: Precedents

- Cite any bad advice you have been given
- Cite peer-reviewed articles concerning the procedure
- Never talk about any of your pain or anguish and never get emotional
* Here, too, Laurie mentioned that anybody she's heard of that ever included this in their appeal was denied - the insurance companies don't care about you or your life, it's all about money
- Send to the right people
* Find the medical director's name, address (sometimes googling or checking your insurer's website works)
* CC attorneys that have won cases against your insurer
- Include cost comparisons showing how paying for your procedure now will save them money in the longrun

Laurie also mentioned that she'd like to see someone on this site be the "keeper of the precedents". While I do plan on starting a thread requesting them, I won't label myself or perform the functions of the "keeper". I suppose this board, in a way (via attachments), could be construed as the "keeper" until someone steps into the role formally. I will also (assuming I write a successful appeal - which Laurie has high confidence in - she's already helped one person get ADR paid for) share my appeal with the community in return for any assistance I get from everybody. Laurie has also promised to send me a version of an appeal that was already written for ADR - with her blessing, I'll post that as well.

I have to say that it was very inspiring to talk to her and I would recommend everyone that has the opportunity to talk to her in person take advantage of it! I had to drive an hour both ways to talk to her, but it would have easily been worth much more of my time than it took. At the risk of sounding like a marketing/PR guy, I'd definitely recommend the book - $15 is pennies compared to what you could save with a winning insurance appeal. If nothing else, buy it to support her in her fight to spread her word so that someday this thread and all the other insurance related threads on this site won't need to exist anymore!

DDD @ L4-S1
PT, Chiro, Decompression, Injections, no luck
Old 12-02-2007, 08:53 AM
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Harrison Harrison is offline
Join Date: Oct 2004
Posts: 7,016

Reposted for MGS32, two different posts (now deleted) that refer to “The Insurance Warrior.”

Hi All,

I recently exchanged a few emails with the "Insurance Warrior" (Laurie Todd) and I wanted to post her responses, in case the answers can help anyone else. I'll post both my question and her response below:

My Question -- I work for a private company, which I've been told is self insured and has more of a health insurance "administrator". (I'm not sure of this, but it's something I need to find out). If this is the case, do you know if this will drastically change the plan of attack I take in making my appeal?

"Insurance Warrior's" Response -- Yes, the fact that the company is self-funded makes ALL the difference in how you approach your appeal.

I've done a few self-funded ones, and I have written an article about them. I will also send this to you when I get home.

With a regular insurance plan, the insurance company gets to decide if you get your treatment. When they deny your treatment, you intimidate the insurance company until they pay. The insurance company is subject to state insurance law, and the Insurance Commissioner can be of help, or take your complaint.

In a "self-funded" plan, your employer gets to decide whether you get your treatment/surgery. The money to pay for your surgery comes directly out of the employer's checking account, so they get to decide. In this arrangement, there is no insurance company. All of a sudden, the insurer (Blue Cross, Regence ... no matter who they are) magically turns from an insurance company to a "third party administrator." Your employer is not considered by law to be an insurer, and your insurer is not an insurer.

So ... in the self-funded plan, the insurer and employer are not subject to insurance law, and the Insurance Comissioner cannot help you.

If your appeal gets denied enough times (depends on the plan, usually three or four), the only entity that you can appeal to is the FEDERAL GOVERNMENT (Dept. of Labor). Good luck with THAT! The appeal time with the D.O.L. is six months. Forget it ... you must write an appeal strong enough to nail both the insurer and the employer before you get to that point.

One of the gnarly things with self-funded plans is that the "insurer (third party administrator)" and the employer may hide behind each other. If you talk to the insurer, they say, "We don't have any power to approve this." If you talk to the employer, they say, "We just go by what the Medical Director of the insurance company decides."

Some of the smaller companies who use this set-up totally don't play by any kind of rules, because there is absolutely no regulation of their "insurance" activities. I remember one ADR case where the employer said, "Your husband is a high-level manager here. He already has more benefits than most other employees. If we GIVE you this surgery (as though it were a gift of some sort), other employees will be jealous."

OUTRAGEOUS. If there is any law against it, it is probably a labor law, or some kind of federal statute. If that were me, I would have dug until I found it ... and totally rubbed their noses in it. This person gave up at that point, because she was afraid of further antagonizing the employer.

I fought one of these in person with a local couple. The employer was Boeing, and the "third party" was Regence ... it doesn't get any bigger than that. I had to aim directly at the head of the Medical Director of Regence, and directly at Boeing. It was an in-person hearing. Six Boeing vice presidents, two Medical Directors of Regence, and one corporate attorney. I wrote a speech for the patient's wife, and a speech for me. It was extraordinarily tricky, extrarodinarily difficult, scary as anything. We wiped the floor with them, and they decided to pay within twenty-four hours.

It was after that case that I decided not to get that involved with future appeals.

You need to request your surgery, get denied, and find out where the resistance is coming from. Then, you need to ditch all fear of insurance companies, and all fear of employers. You must intimidate both parties sufficiently to get the job done (make them pay). You must be so intimidating, and so excruciatingly polite, that they don't even THINK about retaliating.

These self-funded plans are horrible news for employees who get sick or need expensive healthcare. Not only do you lose protection of insurance law and the insurance commissioner, but you often have to fight your employer when your are really sick, and most afraid of losing your job. Worst aspect of self-funded plans? The company sets aside x-number of dollars each year to pay for medical treatments. If you come down with cancer towards the end of the year (or fiscal year), they will be just plain out of money, and you just plain won't get any treatment.

Why do companies go for the self-funded plans? They didn't work back in the 1970's, and they don't work now. Companies go for them because they are advertised as "money savers" by the insurance companies. The company gets to save money because the premiums are less than for traditional insurance, and the company gets to control the purse-strings. Further, the insurance companies aggressively push these plans, because a self-funded plan instantly frees them from all regulation.

Find out how the two sides work together at your company. Who is calling the shots, who is standing in your way? Then, put on your velvet gloves, and wield your mighty sledgehammer of facts with the precision of a scalpel.

Feel free to share this verbiage on the ADR website ... I like to help the greatest number of people. Just tell 'em where it came from.

Laurie Todd
The Insurance Warrior

Hi All,

One more email exchange I had with the Insurance Warrior that I wanted to share...

My Question: My question is whether I should hold off on having my doctor's secretary send in a pre-determination letter for my insurance until the ProDisc-C has been FDA approved. A little background: My neurosurgeon told me last week that he had received word that, as of the 1st of the year, he would be able to use the ProDisc-C at two levels off trial. On October 25th, Synthes received the Approvable letter from the FDA for the ProDisc-C, but they have not yet received FDA approval. I spoke to the director of reimbursement at Synthes today, who told me they expect to get FDA approval very soon, but he could not give me an exact date. I assume that my doctor must have been at some conference where this announcement was made that Synthes expects approval by the 1st of the year. So, the director of reimbursement told me I was crazy to submit for insurance approval before FDA approval was announced. Of course, I am anxious to get this process started so that I can hopefully get surgery soon and start feeling better. But, I don't want to hurt my chances by applying prematurely. Any advice/suggestions you have would be great!

"Insurance Warrior's" Response - These "Directors of Reimbursement" ... what do they do? They pay them good money, I presume.

The first of the year is not that far away. However ...

You've read the book by now, yes? What does "experimental" mean? THERE IS NO DEFINITION OF IT. IT MEANS THAT THEY DON'T WANT TO PAY.

They (employer/insurer) don't care if the treatment is good for you or not, is proven or not, is FDA-approved or not. Why doesn't this "Director of Reimbursement" know this?

Insurance companies deny treatments that are FDA-approved every day of the week. They call treatments "experimental" that they have paid for hundreds of times, that they just paid for last week.

Furthermore, when they receive our blockbuster appeals, they paid for treatments that are NOT FDA-approved, that are only offered in other countries, that they have NEVER paid for before. Why? BECAUSE WE INTIMIDATE THEM INTO IT.

By all means wait a month for FDA approval if you want to. However, waiting for such a thing demonstrates that you haven't totally wrapped your mind around this denial of care thing and how it really works.

Just know that an insurance company has NO CRITERIA WHATSOEVER for deeming treatments "experimental" or "not medically necessary." They don't know, they don't care. That's why all of these appeals that detail your terrible quality of life, explain why the treatment will help you, etc. will fail. BECAUSE THEY DON'T CARE ABOUT ANY OF THAT.

It is simply their job not to pay, and your job to make them pay.

You make them pay by preparing a twenty-plus page appeal document. Don't give your whole medical history ... they already know that. Only tell the things that the in-network doctors did wrong. List a dozen different cases (name names, give dates and surgeons) where they paid before. Prove that the treatment is tried-and-true, with excellent results. Attach peer-reviewed articles to meet all objections. Omit all feeling words, sound like the most polished attorney. Make certain that your appeal document gets to the right decision-makers, with copies to important people who will check up on your addressee.

This is all in the book, I've restated it in the Ten Steps. Do exactly what I say, and they will pay.

Share this with your friends on the ADR site, and please remember that -- for both you and the insurer -- this is all one high stakes chess game, one big bluff.

Thank you for letting me rant a bit. They should be paying me instead of all these Reimbursement Specialists. I have won twenty-eight of these, and lost zero. They, from what I have been told, get about a 50% approval rate. I seem to be the only one who understands that this whole denial of care thing is all smoke and mirrors. The insurer is not waiting to be convinced. They are waiting to see if you are clever enough to call their bluff.

"Harrison" - info (at)
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
Old 12-04-2007, 06:38 PM
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Harrison Harrison is offline
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The Insurance Intelligencer

The Peer Review

What is the “peer review,” and how can we turn it to our advantage?

Let me take this opportunity to explain—one more time—that the health insurer’s assertions and objections are all smoke and mirrors. Following is a quick refresher course, just to get you in the correct analytical state of mind:

1. What does “experimental” mean?

Nothing. Whatever your health insurer says it means. There is no agreed-upon definition for “experimental.” No matter how I explain this, folks still try to make sense out of these pronouncements by the insurance company. They say, “It must mean ‘not FDA-approved,' right?” Wrong. Health insurers deny FDA-approved treatments every day of the week, and they approve treatments that are not FDA-approved every day of the week. But only if we submit a powerful written appeal to the right decision-makers.

2. If my out-of-network benefit is 80%, I have to pay the other 20%, right?

Wrong. If you write a strong enough appeal, tell all of the things they did wrong in your treatment, quote all the incorrect and embarrassingly untrue things the in-network doctors said, and list two dozen times they have paid for this before, they will be eager to pay the in-network rate, with no patient responsibility. Every item in your benefits booklet is negotiable, except the lifetime maximum.

Onward to the peer review ...

Let’s say that you request a treatment/surgery/medication, and your insurer denies the treatment, stating that it is “experimental, out-of-network, not medically necessary.” At some point in the entire appeals process – could be after the first appeal, could be later – your case may be sent for a “peer review.”

I’ve put you in the appropriately suspicious state of mind, yes? What exactly is this peer review? Many never ask this question. The insurer comes back to them, saying, “The peer reviewer has denied the treatment.” Cast in stone, right? A doctor who is expert and informed about this treatment has said “no,” right?

NOT NECESSARILY. Just start digging, and you may be able to show, once more, that the Health Insurance Emperor Has No Clothes.

One of my brilliant helpees was involved in requesting a very cutting-edge, state of the art radiological treatment for liver metastases. The radiation oncologist who administers this treatment has a twenty-page resume, and a list of published papers as long as your arm.

The case manager says, “The case is going to the peer-to-peer review.”

My helpee managed to weasel the name of the reviewer out of his case manager. Guess who this “peer” was ... a family practice doctor with no special training in oncology, radiology or liver tumors who works for the insurance company. He denied the treatment within one day ... do you think that was long enough for him to study up on the latest treatments for liver metastases?

Dr. Hired Gun’s job is, I suspect, similar to the job of the doctor who is employed by the auto insurer. You know, the one who finds all the ways in which you are not injured.

Once we figure this out, how do we turn it to our advantage?

Simple. Make it a point in your written appeal. Find out who the “peer” is. Make a few statements about the qualifications of your expert-of-choice, and a few more statements about the complexity of the treatment. Mention the three hundred peer-reviewed studies by your doctor-of-choice. Then say, as naively as possible, “Dr. Expert is a surgical oncologist with thirty years experience doing this incredibly complex procedure. I was surprised to learn that Dr. Hired Gun is an OB/GYN, two years out of medical school, who is employed by Acme Insurance.” The assumption being ... your peer was not a peer, and his review holds no water.

Now THAT will be very embarrassing to Acme Insurance, when they see it in print.


Philosophy Corner

This is my last newsletter of the year; it is time to wax philosophical.

In December 2005, I was sitting around listlessly in my Pillsbury Doughboy pajamas at my friends’ home in Washington, D.C., watching HD TV all day. I had just been sprung out of the hospital after undergoing the Mother of All Surgeries and spending forty days of suffering in the hospital – relieved only by several near-death experiences. I did not know if I would ever have the strength to pour my own glass of juice, and I didn’t have the strength to care.

December 2006. I had by now won two dozen appeals for others, written a book, found a cancer foundation to fund the project.

December 2007. This year, I published the book myself, sold two thousand of them, helped win another dozen appeals, and started the speaking career.

December 2008? I would like to speak at many conferences, sell many boxes of books, and affect how health insurers decide about care. Publish a second book – how about a do-it-yourself appeal workbook, with jaw-dropping helpee success stories woven in? I think big ... who would have predicted what I have done since I was told in March 2005 that I had months to live, and that there was no treatment for my disease.

Perhaps the most important work that I have done during the last three years is to grow in compassion. Sometimes painfully, but always to the good. And to use the words “good” and “bad” much less, choosing instead “desirable” or “undesirable.” Cancer? Undesirable. Becoming a published author? Desirable. Both part and parcel of the ten thousand joys and sorrows that comprise a full life.

Thank you to my readers, friends, and helpees for being brilliant and compassionate participants these past three years ... and for many years to come.

************************************************** **
Need an inspiring gift? One size fits all? How about the book “Fight Your Health Insurer and Win”? Let’s hire me to speak at conferences,get these books to those who need them, and make room in my storage unit for Book Number Two!
"Harrison" - info (at)
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
Old 04-15-2008, 06:20 PM
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Harrison Harrison is offline
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The Insurance Intelligencer

“The Doctor Wrote my Appeal”

When I first heard this, I was baffled. I wondered ...

1. Whose doctor would write an appeal?
2. What kind of an appeal would a doctor write?
3. Why would a patient trust anybody but themselves to write an appeal?

If you had asked me three years ago, “Why don’t you have your doctor write an appeal?” ... I would have laughed till I cried. Not only weren’t my local doctors interested in writing an appeal, but they were dead set against me getting any treatment at all, saying ...

1. “You don’t need any further treatment.”
2. “There is this Dr. Sugarbaker. However, if you went to him, you would be disabled.”
3. “There is no treatment for your disease. And, even if there were, they wouldn’t pay for it.”

Like I would trust any of these individuals to write an appeal for me?

I have learned much in the last three years. When people find themselves in Big Medical Trouble, their first reaction is to call the insurance company. Once they figure out that they aren’t getting anywhere with their insurance company by phone ... they call their doctor.

Once upon a time – before the coming of Managed Care in the 1970’s – your doctor would have been the one to call when the insurer said “no.” Back then, your doctor’s practice was an independent entity. It was his job to find the best treatment for you, to request it of the insurance company, and to persuade them to pay for it.

Back in 1970, in their quest to control skyrocketing medical costs (How well has that worked?) the insurers came up with a brilliant concept. Let’s build a building, put all the doctors in it, pay them a salary, and put a contract in place that says that the INSURER gets to decide what treatments get paid for.

Voila, the HMO is born. PPO, POS – whatever type of insurance you have, your doctor is contracted with the insurance company, and you live according to the principles of managed care.

There are two types of doctors that you will encounter: Doctors who are contracted with your insurance company (in-network), and doctors who are not contracted with your insurance company (out-of-network). Let’s see what happens when each type of doctor writes your appeal.

In-network doctor writes appeal

He is contracted with the insurance company. Therefore, it follows that he is not in the best position to mount a powerful appeal to make the insurer pay for something they don’t want to pay for.

Sort of like a quarterback going for a touchdown for the opposing team.

Out-of network doctor writes appeal

The doctor who is not contracted with your insurance company (often your expert of choice) has no influence with the insurer whatsoever.

What repercussions are there if an out-of-network doctor asks for a treatment for you, and the insurer still says no? None.

See where I am going with this?
The only person who has any traction with your insurance company is YOU.

What kind of appeals are doctors writing?

In 99.9% of cases, they are not writing appeals at all. Best case scenario, they write a one-page letter saying, “The patient really needs this treatment.” More likely, they have a form letter in their files that says, “The patient really needs this treatment.”

There is an exception to every rule, of course. I have met one doctor who personally engages in appealing insurance companies. It is very frustrating for him, and it takes away from the highest and best use of his time, which is performing lifesaving procedures.

I have advised him more than once to buy a supply of my books, issue one to each new patient, and get the patients on board to write their own appeals.

When your life is on the line, is a one-page form letter good enough for you?

Laurie the I.W. speaks to an Appeals Coordinator

A prospective cyberknife patient contacted me ... her first two appeals had failed. I asked, “What did you put in the first two appeals?” “My doctor did the appeals,” she answered.

She then suggested that I speak to the Appeals Coordinator. I eagerly anticipated speaking to someone who actually gets paid for what I do.
I asked the paid appeals expert, “What did you put in the first two appeals?”

“Well, it was a letter,” she replied.
“How long of a letter?” (Laurie)
“One page and some articles.” (Appeals Coordinator)
“How many articles?” (Laurie)
“Two.” (Appeals Coordinator)

Two. I almost fell off my chair. Since I have no censor anymore, I said, “When I write the third appeal, the letter will be twenty pages long. I will attach at least twenty-five peer-reviewed studies and articles (specifically about cyberknife and liver tumors). I will go to the FDA website, and find written proof that the cyberknife equipment is FDA-approved, and exactly what kind of FDA approval it has. Then, I will go to the CMMS (Center for Medicare and Medicaid Services) website, and find the written evidence that Medicare is reimbursing for cyberknife for liver lesions.

Then, I will go out into the online support groups, and find thirty-plus cases where major insurance companies have paid for this before (precedent).

Bottom line? Do not leave it to your doctor to write your appeal.


Would you like Laurie the I.W. to speak to your group?
Just ask, and I will send you my Speaker Info Package.

Isn’t it time that your medical provider issued a copy of my book to every new patient? I will be happy to send him or her my Provider Package.

Happy and peaceful Insurance Warrior-ing,

Laurie Todd
laurie (at)
"Harrison" - info (at)
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
Old 05-28-2008, 08:49 AM
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Harrison Harrison is offline
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Posts: 7,016

Just an update from our friend Laurie Todd...

Dear friends, readers and helpees --

The Insurance Warrior was featured on the Seattle news yesterday.

If you want to see me in person -- making a spectacle of myself in front of thousands -- here is the link (copy and paste):

Please share with everyone who has health insurance, anyone who needs a keynote speaker, and all who need to hear this message.

Peaceful Warrior-ing to all,

Laurie Todd
"Harrison" - info (at)
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
Old 05-30-2008, 01:25 PM
ans ans is offline
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Join Date: Mar 2005
Posts: 1,596

This is probably incidental but I've written to Laurie and she seems like a very nice person.
Severe, extensive DDD, considered inoperable by Dr. Regan, Lauressen, & some guy at UCLA. Severe foraminal stenosis (guess they can't operate!) and some spinal cord compression that Lauryssen would fix if gets outta hand.
Old 06-18-2008, 04:49 PM
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Harrison Harrison is offline
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Posts: 7,016

The Insurance Intelligencer 6/15/08
It's YOUR Appeal

Last week I received an email from Jean. She had read my book, and she had a question:
"My husband needs Erbitux. The appeal has been denied. Our next recourse is the Department of Managed Care. Any tips for us?"

I already knew from this message that Jean didn't get it. However, I asked a few questions in order to get Jean to realize that she hadn't gotten it.

1. Why is it that most insurers do not want to pay for Erbitux?

Jean's answer: The money?

Jean hasn't done her research. She doesn't grasp yet that, if appeals are all about money, then we have to know exactly how much everything costs. How much does our requested treatment cost? What treatment would Acme Insurance rather offer you, and how much would THAT cost?

Erbitux (Cetuximab) is the most expensive prescription drug on the planet. A monthly dose costs at least $16,000. Erbitux is a perfect example of an exciting new cancer treatment. The only thing not so exciting is that all of these new cancer treatments will be scary-expensive, and your insurer will not want to pay for them.

You need to know what you are asking from your insurer, money-wise, before you even consider writing an appeal.

2. Who wrote the appeal that failed? What was in it?

Jean's answer: My doctor wrote the appeal.

As my loyal fans and readers know ... "My doctor wrote the appeal" is not an answer. If your doctor is contracted with the insurance company, he is not ideally positioned to mount a powerful appeal for you. If your doctor is not contracted with the insurance company, he has no say with them whatsoever.

Most doctor-written appeals are one- or two-page form letters, which say, "The patient really needs this treatment."

Is that good enough for you?

If you didn't know better at the time, and the doctor did write your losing appeal ... GET A COPY OF IT. Before you can write your own winning appeal, you need to know what didn't work.

3. How do you know that your only recourse is the Department of Managed Health Care?

Jean's answer: We were told ...

"We were told" is not an answer, unless it is immediately followed by " ... and then I looked it up myself."

People, please. When a treatment is denied, the first thing to do is go to your benefits booklet (or the insurer's website), and study their appeals procedure. This is your roadmap, your pathway to approval, your freeway to success.

It is incomprehensible to me that someone could already have one denial, not have any idea what was in the failed appeal, and not know for themselves what levels of appeal were available to them.

Don't ask ME what appeals are available to you ... that is up to your insurance company. By law, this appeal information must be provided to you. It is part of your job as an Insurance Warrior to know the appeals procedures, and follow them to the letter.

By the way, if you call six people at Acme Insurance about appeals, you will get six different answers. "We were told" is a very dangerous -- often fatal -- condition in which to remain.

My questions to Jean regarding where she stands in the appeals process:Who told you? Do they know what they are talking about? What does it say in your benefits booklet? Usually appeals don't go straight from one denial to a government agency.

Since you are under the impression that you must now rely on the Department of Managed Health Care (a California government agency) ... have you studied all about them, and researched THEIR appeals procedures?
I pointed out to Jean that we do not expect government agencies to win our appeals. We do not expect doctors to win our appeals, we do not expect lawyers to win our appeals. We do not expect insurance brokers to win our appeals, we do not expect politicians to win our appeals. And we certainly do not expect Insurance Commissioners to help with our appeals, much less win them.

Whatever you do, I told Jean, write your own appeal. If you must submit some type of form to the Department of Managed Health Care, make your twenty-page appeal an answer to one of the questions, attach it ... and be sure to copy the right decision-makers. Who should you copy?

- The Medical Director of the insurance company
- Two suitable Vice Presidents of the insurance company
- The Executive Director of the Medical Society of your state

No government agency is ever going to move fast enough to save your life. If you have to funnel your appeal through a government agency, you need to get it back through the doors of the insurance company, through your "carbon copies." If you have written a powerful-enough appeal document, the insurer will approve it before the Department of Managed Health Care ever gets around to looking at it.

Thankfully, we are on our own when it comes to writing and winning our appeals, because nobody will ever do a better job than we will.

Of course, it will be much easier for you than it was for me, because my book explains exactly how it's done:

Fight Your Health Insurer and Win: Secrets of the Insurance Warrior Available exclusively at my website:

Or invite the Insurance Warrior to present a seminar or talk to your group.
Contact: for the media package.

Happy and peaceful Insurance Warrior-ing!

Laurie Todd

If you haven't watched the YouTube video yet, take a look, and leave a comment!
"Harrison" - info (at)
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
Old 06-18-2008, 07:52 PM
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Terry Terry is offline
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Join Date: Oct 2006
Posts: 1,210

Nice Post. It basically tells us that our destiny is in our own hands, where it should be.

To thine own self be true.

She has excellent advice and a road map to follow.

Thanks for posting this Richard and I hope it helps a great many people.

Terry Newton
1980 ruptured L4-L5
1988 ruptured SI-L5
1990 ruptured C5-C6
1994 ruptured C6-C7
1995 Hemi-Laminectomy C5-C6, C6-C7 Mayo Clinic
Bicycle Accident 2004
MRI, EMG, Facet Injections, Epidural Blocks, Lumbar Discogram.
Stenum Hospital Surgery November 4, 2006
Prestige Disc C5-C6, C6-C7
Maverick Disc S1-L5, L4-L5
Old 10-12-2008, 11:38 AM
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Exclamation The Insurance Intelligencer

The Insurance Intelligencer : 10/10/08


Insurance Company Words

Treatments are denied with words, and treatments are approved with words. I win all of these appeals because I understand insurance company words.

I have an M.A. in French Literature. This unlikely credential means that I am trained as a literary critic. To me, all words are propaganda. And it is my job to figure what they are trying to brainwash me to do.

Insurance words have two goals:

1. Make you feel very, very safe and cared for.
2. Keep the power in their hands.

Once we understand how insurance propaganda is deployed, we will not be stopped by it. As a matter of fact, we can use it to our advantage.

Names of insurance companies

Let's begin at the beginning. The name of the insurance company is designed to make you feel that they are on your side, and that they will keep you safe. What is the name of your insurance company?

Blue Cross/Blue Shield ... The insurer is my cross and my shield.
United Healthcare ... We are united. We have health. We CARE.
Neighborhood Health ... We are your friendly neighbor.

My favorite insurance name of all time? A man from Illinois called me. He had had brain surgery, and the insurer didn't want to pay for it. I asked, "What is the name of your insurance company?" He said -- I kid you not -- "Golden Rule Insurance."

Do unto others as you would have them do unto you. For crying out loud ... how would the Medical Director of your Golden Rule Insurance like it if they wouldn't pay for HIS brain surgery?

Don't be lulled into complacency by the name of your insurance company.

Names of departments at insurance companies

It used to be called "customer service." We are eager to serve you. But customer service has been amped up to "Customer Care." We CARE, we really do.

United Healthcare gets the Laurie Todd Hooplehead Award for the most devious department name of all time. A nice gentleman from Wisconsin called me one day. He had a rare form of testicular cancer, and UHC suddenly stopped paying for the only treatment that was keeping him going. He send me a heartrending account of the hundreds of fruitless phone calls that he had made to UHC, the call-back promises that were never kept, etc. Guess what department he was dealing with?

The Rapid Response Resolution Team

The job of the Rapid Response Resolution Team is to never, ever, under any circumstances call you back.

Names of people at insurance companies

Peope at insurance companies keep the power by not telling you their names. They will give you their first name, and a phone extension. Ever try to call that extension? They never work. Joke's on you.

What message does withholding of names send?

o I am not accountable.
o You will have to tell the whole story all over again next time.
o Any promises that I make are empty.
o I am really not here to help you, and I don't care.

My favorite name incident of all time? One of my helpees called the insurer, and asked for the name of the Medical Director. The "customer care" person answered, "Oh, we are not allowed to speak his name."

Is this like the thousand names of God? We dare not speak his name? I know that Medical Directors have divine rights over our life and death, but this is ridiculous!

Denial of care words

Now we understand that words are meant to persuade. We will not take them at face value. Insurance companies always use the same three phrases to deny care. What are they, and what do they make us feel?


When I ask people what experimental means, they say, "not proven," "no randomized trials," "not FDA-approved." I have news for you. Insurance companies have paid for treatments that weren't FDA-approved, and they have denied treatments that are FDA-approved. Denial or approval is totally capricious.

There is no "experimental" list. Insurers have denied treatments as experimental, when they just paid for them last week. They have denied treatments as experimental, when they have paid for them hundreds of times. There is no substance, rationale, or logic behind these denials.

If your treatment is denied as experimental, just look up your insurer's definition of experimental, and disprove it in your appeal.

Not medically necessary

Does this mean "not needed for my health"? "Not needed for me to survive"? Has my insurance company done a lot of research to determine whether I need this treatment or not?

People, please. "Not medically necessary" is not a medical term. It is a legal term. This phrase was invented along with managed care back in the 1970s. It removes decision-making power from your doctor, and grants it to the insurer.

Go to your benefits booklet, and read their definition of medical necessity. Somewhere in the bewildering paragraphs of legalese, it will say: "Medically necessary as determined by the Medical Director of Acme Insurance Company." Because we said so.

Leap over this objection, there is no substance to it.

Out of network

The lifesaving treatment that I need is out of the network. I have no out-of-network benefit. That means that I have to sell my house to pay for it, right?

Wrong. If your health will suffer without this treatment, they can be persuaded to pay for it. Simply go to my new improved website, and use the appeal template from my "Winning Appeal Workshop," ( and plagiarize to your heart's content.

The emperor has no clothes. Denials are bluffs. Just make your bluff better than their bluff, and you win.


Catch my WEBINAR on Tuesday, October 14 -- 3:00 p.m.
You need to register, and it is FREE
"Harrison" - info (at)
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
Old 11-05-2008, 07:30 PM
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Default The Insurance Intelligencer - November 5, 2008

The Insurance Intelligencer

Lifetime Maximum

People often ask me, "What is the most pressing issue about health insurance?"

Snarky answer? All of them.
Two-word answer? Cost shifting.

In case you haven't noticed, your health insurer is constantly finding new ways to shift healthcare costs to you:
  • Higher deductibles
  • Multiple deductibles (office visits, drugs, out-of-netword, hospitalization)
  • Higher co-pays
  • Higher out-of-pocket limits
  • Higher costs for going out-of-network
  • Out-of-network maximums
  • Shorter list of covered prescription drugs
  • Yearly maximums for prescriptions
  • Varying percentages paid for different lists of drugs
Once these cost-shifters are in place, you will be surprised how fast the expenses add up. You have "good insurance." You are diagnosed with breast cancer, or colon cancer. Within a year, you could easily rack up $50,000 in medical expenses that are not covered. Happens every day.

So ... you mortgage the farm, sell the horse, and get through your first year of cancer survival. At least you still HAVE insurance. Or do you?

Insurers have two ways of cutting you loose, when you become too expensive (i.e., sick): Recission, and the lifetime maximum.


Recission is the lesser problem. However, it does happen, and you need to be aware of it.

The word "recission" means "the cancellation of a contract." This is how it works. You are diagnosed with cancer. You ring up many dollars in medical expenses. When you reach a certain dollar amount, bells and whistles go off over at Acme Insurance. "Beeep! This member is getting too expensive!"

The bean-counters at Acme then pull up your original application, and pore over it to see if there are any irregularities that they can seize upon, in order to cancel your policy entirely. These "irregularities" are often made to fit into the category of "pre-existing conditions." Insurers have gone so far as to assert that you had an ache or pain ten years ago, you should have known that you were going to get cancer, we're cancelling your policy.

Recission is not practiced by all insurers, because it borders on the illegal. Anthem Blue Cross recently settled a lawsuit for $11.8 million dollars ... for "unlawful and deceptive business practices" -- claim denials and unjustified recissions.

Recission is easily overturned with a powerful appeal, so I am not overly alarmed about it. There is, however, a looming danger to all insured people. They can get rid of you, and there is nothing that you or the Insurance Warrior can do about it.

The Lifetime Maximum

The majority of us have a lifetime maximum. The most common figure is $2 million. Sound like a lot of money? I have seen people with cancer run through $2 million in eight months. Eight months is not a lifetime.

When you have maxed out your health insurance, you are done. Cut off. It's cash out of pocket from that point on.

The current lifetime maximums were set back in the early 1970s -- by insurance companies. They have not been raised since. I do believe that, in 1970, the insurers made a good faith effort to figure out how much it would take to cover the average person for a lifetime.

In 1970, my grocery budget was $15 a week. The medical care that cost $2 million in 1970 would cost approximately $36 million today.

Why have these lifetime maximums never been raised? Because it is not to the economic benefit of insurance companies to do so, and there is no law requiring them to do so.

More people are maxing out their insurance every day.

What to do when you max out your insurance? Some states have a risk pool of "uninsurables," which is what you now are. Sounds a little bit like "undesirables," doesn't it? The coverage is expensive, and limited to the basics. You get to be on their waiting list after you run out your insurance, then get turned down by two insurance companies.

Keep an eye on your lifetime max. This is the fixed amount that your insurer will ever spend on you. It is your "medical checking account," and it dwindles with every treatment you receive. Use it wisely.

Plus -- when we have new elected officials -- implore them to reign in the wild horses of health insurance, and make them raise these lifetime maximums that are forty years out of date.

Check out my free Winning Appeal Workshop

Ask a question! Leave a comment!

Happy and peaceful Insurance Warrior-ing,

Laurie Todd
"Harrison" - info (at)
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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appeals process, erisa, independent review, independent review organization, insurance appeals, insurance commision, laurie todd, medicare compendia, nairo, the insurance warrior, third level appeal

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