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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 11-05-2008, 10:53 PM
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Terry Terry is offline
Senior Member
Join Date: Oct 2006
Posts: 1,210

Working in the health care industry I am always amazed at how people with insurance are paying for people without insurance. This is truly one of the bigger reasons why our premiums are so expensive today. I am very opposed to Universal Health Care but, something drastic has to take place as there are now 46 million people uninsured in America today and growing every day.

I am more supportive of requiring everyone to have health care insurance. This would cause the costs to go down across the board as we would not be forced to pay for people who do not have insurance. Make the contribution towards their family policy determinate on the amount of their family income.

This solution could work as it requires us to be responsible for ourselves. There needs to be some healthy initiative incentives to get people take better care of themselves. The policy amount is determined by the income level of the family but, also tied in to their lifestyle choices. Obesity, drinking and drugging, lack of exercise, smoking, etc. would cause premiums to increase to make up for the loss of revenue associated for taking care of people who make unhealthy lifestyle choices.

How about it all?

Time for a new beginning?

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 11-06-2008, 01:16 AM
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KBear KBear is offline
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Join Date: Sep 2008
Posts: 163
Angry Health Care in America

I am definitely not for universal health care either; but something has got to give. My family spends $1,200 a month on co-pays, prescriptions, out of pocket, deductibles, and premiums (and no one has had any major surgery). This is $14,400 a year, some people don't even make that in a year. Others make double, maybe triple that. Even at an income of 3x that, $43,200 a year, that would make your medical spending 33% of your income. How in the world does one support a family and pay that kind of money? I am very fortunate that we are able to afford that and still live comfortably, but so many can not.

For instance, my brother got married 2 years ago, at age 28. He and his wife, 26 years old, bought a home (the American dream), and started building their life together. Like so many of us (myself included), as a young married, health insurance was the furthest thing from my mind. We were young and healthy and had 'better' ways to spend that premium, thus making the choice to forgo insurance. They checked into insurance and decided it wasn't in the budget; but were planning on getting it in a year and planning to start a family. One year and two months after the wedding, my brother was shocked to find a lump in his testicle. He went to the doctor, thinking that it was nothing; but got it checked due to his wife's insisting (her mom was battling breast cancer and she was in high alert mode). The doctor decided he wanted to have it surgically removed and do further testing.... A month before my brother turned 30, he was diagnosed with testicular cancer that had already spread to his stomach and lungs. He then began cancer treatment, with no insurance. He did have a small 'nest egg' set aside, which didn't last long. He paid 10K to have a central line implanted.

Another 12k for testicle removal, numerous testing, etc. It was not long before the 30k 'nest egg' was gone. He then had his first chemo, in the hospital, since it was so strong that he was high risk for having his body shut down and needing to be brought back. They put money down and made a payment plan upon admission. The plan was for 5 days in, 8 hours a day of chemo, then 3 weeks 'off', with one outpatient treatment for 8 hours at the hospital each week, then 5 days 8 hours in hospital. He finished he first 5 days in the hospital and returned 4 days later for his outpatient day and was refused treatment. He was told that without paying the bill in full for the prior treatment he could not be treated, even though he had made a down payment and payment arrangements. He did not qualify for goverment assistance as his income was too high. He has been fortunate to have a dr who helped him get discounted chemo in the dr's office, as well as family and church family who have contributed financially to his care. This is all because he made a gamble on his health, by having no insurance and lost. One year later he is saving to have a 'mass' removed from his stomach, which may or may not be cancer.

Then, back to testing for cancer clearance. Also, he will NEVER be insurable, no one will take him with cancer in the history, no life insurance, nothing. All for one case of bad judgement in not having insurance. We, as Americans, can not allow our fellow Americans to die for bad judgement, lack of money, or unforseeable circumstances; something has got to change. Although, from what I have read and heard about Canada's health care system, that is not the answer.... months waiting for a dr visit, a diagnostic tool, a surgery, etc. that could be life or death for many. Stepping off my soapbox now....
Old 12-09-2008, 03:27 PM
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Harrison Harrison is offline
Join Date: Oct 2004
Posts: 7,016
Default The Insurance Intelligencer: 12/8/08

The Cure for Cancer

We donate for the cure. We research for the cure. We climb, walk, race for the cure.

When the cure is found ... it will be very, very expensive.

What good will that cure be, if your insurance won't pay for it?


One day, you are sitting in your doctor's office, worried and waiting. He tells you that you have cancer. What treatments will be offered to you?

What treatments will your doctor offer?

The ones that he happens to know about. He is not all-knowing.

The ones that he approves of. His criteria may not be the same as yours.

Generally speaking, he will offer the treatments that are available within the insurance network.

Disclaimer: Many of your doctors are providers for the insurance company, and will fight the insurance company if necessary in order to get the best treatment for you. We cannot assume that all doctors are doing this, however.

The insurance company is a business, not a social service agency. When you meet with your doctor, your are sitting face-to-face with the representative of the insurance company. It is his job to reduce operating expenses, by controlling access to services.

I am not being cynical. That is his job. He is the gatekeeper.

Of course, it is also his job to treat whatever medical problem you came in with. Sound like a pretty serious conflict of interest? It is, for all concerned.

The simplest way for your doctor to treat you -- while still controlling costs -- is to offer you whatever treatment is available on his list, in the network, by providers whose fees are determined by the insurance company.

What if your child has a brain tumor, and the only surgeon with the skill and will to remove the tumor does not happen to be contracted with your insurance company? I have news ... many of the most talented and experienced surgeons are no longer contracted with most insurance companies. Don't count on your doctor knowing about this surgeon, or telling you about him.

How do new treatments become standard of care?

Short answer? They don't.

Do you really think that your insurance company is putting forth a big effort to figure out how to shell out more dollars for expensive new medical treatments?

There is no path whereby treatments become "standard of care" for insurance companies. I fight every day for treatments that have been ...
  • FDA-approved
  • Tried, tested, and proven for thirty years
  • Studied in randomized trials
  • Published in peer-reviewed medical journal articles
  • Paid for hundreds of times by the insurance company
Yes. A treatment that Acme Insurance paid for will be denied by Acme insurance three days later as "experimental." Not only is there no path by which new treatments are evaluated and accepted by insurance companies ... they continue to deny treatments that they routinely pay for.

I have fought Regence of Washington six times over the past eighteen months for the same cancer surgery. Each time that a new patient needs this surgery, they call it "experimental" all over again.

How long will it be before the Medical Director of Regence in Seattle tires of receiving my 86-page faxes in the middle of the night? They will fund your effective, proven out-of-network treatment. But only if you are ready to fight for it.

McDonald’s or gourmet?

Much of this research seems to be focused around finding the "magic pill" to cure cancer. Preferably a pill with no side effects, one that my insurance will pay for. However, the likelihood of such a cure seems rather remote to me.

Meanwhile, many patients are having very good outcomes, with very advanced and difficult cancers. The treatment that saves them is not easy, sexy, exciting or new ... it is good old-fashioned skilled surgery.
For many of us cancer patients, surgery is still the gold standard, and surgery is the only path to long years of health with no recurrence.
The surgeon with the best outcomes is not always a provider for your insurance company.

In one of my recent appeals, the insurer denied an out-of-network cancer surgery, stating that the surgery was not "evidence-based medicine." This insurer was currently funding systemic chemotherapy for this patient to the tune of $40,000 to $60,000 per month, with no scientific evidence that it would benefit him. This chemotherapy would continue until the patient died, or couldn't tolerate it anymore.

Since you are spending so much dough anyway, I suggested, why not spend the $40,000 for the definitive surgery that might actually fix the problem?

I believe that I have finally figured out why insurers are so eager to recommend systemic chemotherapy, even in cases where it has never been found to help, and even though it is so expensive.

Each insurer delivers medical care to thousands or millions of people. Sort of like McDonald's, which serves food to millions of customers.

Why is McDonald's offering hamburgers, instead of soufflés?

In order to serve a thousand hamburgers, all you have to do is buy a big vat of nasty factory-farm beef, and deliver it to McDonald's. There, a revolving cast of interchangeable employees are able to turn out identical meals.

Preparing a soufflé, however, requires more expertise, and is more labor intensive. It requires a skilled chef, ready in the kitchen to perform at the top of his game.

In order to treat a thousand cancer patients, all you have to do is buy a big vat of nasty toxic chemicals, and deliver it to the medical facility. There, a revolving cast of interchangeable medical personnel are able to deliver identical treatments.

A curative cancer surgery is more labor intensive. It requires a skilled surgeon, ready in the operating room to persevere until all of the cancer is removed. Surgeries are longer, patients are sicker, and better outcomes are achieved. Not in keeping with the "serve the lowest common denominator" school of insurance-driven care.

Systemic chemotherapy is the best and most appropriate treatment for many people, of course. But not always, and not if the right surgery is more likely to yield a good outcome.

As long as private insurance is in charge, expect to be steered towards the McDonald's burger, not the soufflé.

Perhaps the only one who cares enough to fight for the extraordinary, above-the-norm care is you -- the patient whose life will be saved by it.

Ask me about my new

"Insurance Insider Secret Contacts List"


I know where the Medical Directors are hiding, and I've got their fax numbers!

Happy and peaceful Insurance Warrior-ing,

Laurie Todd
ph: 425 497-1858
"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 12-13-2008, 03:20 PM
ZorroSF ZorroSF is offline
Senior Member
Join Date: Oct 2006
Posts: 303

Originally Posted by Terry View Post
Working in the health care industry I am always amazed at how people with insurance are paying for people without insurance. This is truly one of the bigger reasons why our premiums are so expensive today. I am very opposed to Universal Health Care but, something drastic has to take place as there are now 46 million people uninsured in America today and growing every day.

I am more supportive of requiring everyone to have health care insurance. This would cause the costs to go down across the board as we would not be forced to pay for people who do not have insurance. Make the contribution towards their family policy determinate on the amount of their family income.

This solution could work as it requires us to be responsible for ourselves. There needs to be some healthy initiative incentives to get people take better care of themselves. The policy amount is determined by the income level of the family but, also tied in to their lifestyle choices. Obesity, drinking and drugging, lack of exercise, smoking, etc. would cause premiums to increase to make up for the loss of revenue associated for taking care of people who make unhealthy lifestyle choices.

Terry Newton

I was very surprised by your response, but I could understand it because you are coming from a drug dependence angle. I have to totally disagree with you. "I got mine you get your's" attitude is what created this situation in the first place. It's what even created the Wallstreet crash of 2008. No regulations and no accoutability on behalf of the private medical industry to rake in unlimited cash is what has created these flopsided patient costs. Not the poor or the irresponsible one's.

Most people undergoing spine surgery, much less orthopedic surgery have been taking care of themselves. It's the insurance and medical industry that have been gaming us. It's not the fault of the poor that surgery is so expensive. That's just a false fact that the insurance industry is pushing to get away with stealing money from the insured and the taxpayer.

If you want to solve the medical cost problem in this country you have to look overseas at other industrialized countries and learn from their sucesses and mistakes. Most DO REQUIRE insurance on all citizens, but that is not the reason for high healthcare here since local municipalities in the USA cover hospital and doctor expenses that aren't paid by the patient. That means the hospitals and doctors are getting paid through local taxes. Since state laws require hospitals to take in patients, the hospitals in return require that the local city pay for unpaid bills.

The Swiss example shows that universal coverage is possible, even in a highly capitalist nation with powerful insurance and pharmaceutical industries. Insurance companies are not allowed to make a profit on basic care and are prohibited from cherry-picking only young and healthy applicants. They can make money on supplemental insurance, however. As in Germany, the insurers negotiate with providers to set standard prices for services, but drug prices are set by the government.
1/2006 DDD L5/S1

Prodisc St. Mary's 12/2006 not diagnosed properly pre-op and now have DDD L4/L5, facet calcification L5-S1/L4-L5, mild scoliosis and left knee pain. DDD: C3 through C6

Last edited by ZorroSF; 12-13-2008 at 04:03 PM.
Old 01-20-2009, 12:40 PM
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Harrison Harrison is offline
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Posts: 7,016
Default The Insurance Intelligencer - 1/19/09

The Insurance Intelligencer

Usual, Customary and Reasonable

The phrase "Usual and Customary" has been in the news recently. "Usual and Customary" nets health insurers billions of dollars every year. It puts dedicated medical providers out of business. It costs patients hundreds of millions of dollars that they never expected to spend.

The tables were turned last week. The Attorney General of New York took a long, hard look insurance company reimbursement policies, and "Usual and Customary" just cost United Healthcare fifty million dollars.

Remember, the entire insurance industry runs on words. Words with secret meanings. Words that the insurance company uses to shift costs from themselves to you, and to your doctor. Words which are carefully crafted to make you not question.

What words do health insurers use to save money BEFORE you get your treatment? They deny the treatment, by deploying the words "Experimental/Investigational." Most patients believe that the insurer has some type of proof behind these words. Further, they have no idea how to prove that the lifesaving treatment which they need is NOT experimental. So they give up.

What words to health insurers use to save money AFTER you get your treatment? "Usual and Customary." UCR is a mystery to even the most sophisticated medical consumers.

Let's see how it works ...

A new person calls me with insurance troubles. He needs very expensive out-of-network cancer treatment. I ask, "Do you have a PPO, or an HMO? He replies, "I have a PPO, so I can go wherever I want." I continue, "If you go out of network, how much will they pay?" People invariably reply, "80% (or 70%, or whatever percentage).

Then I ask the quiz question: "80% of what?"

I have asked this question of attorneys, bank vice presidents, college professors. Nobody has ever answered the question correctly.

80% sound like "a lot," doesn't it? No matter how much it is, I won't have to pay much, right? WRONG. Your insurer is not offering to pay 80% OF BILLED CHARGES. They are offering to pay 80% of Usual, Customary, and Reasonable charges.

Wait just a doggone minute? Usual and customary according to WHOM?

The one surgeon who can remove your difficult brain tumor is not contracted with your insurance company. Since you are especially diligent, you obtain an estimate for the surgery plus hospitalization: approximately $100,000. You say to yourself, "OK, I can manage to pay the $20,000 that they won't cover."

You have the surgery, return home to recuperate, and the bills start rolling in. Here is how UCR works. Your insurer deems ten percent of your $100,000 treatment to be "usual and customary." That would be $10,000. They pay 80% of that amount, which is $8,000. Since there is no contract between your insurer and the out-of-network doctor, the doctor is perfectly within his rights to balance-bill you for whatever the insurer doesn't pay: $92,000.

The surgeon who saved your life can either take a huge loss ... or bill you, and look like the bad greedy guy.

You may well ask, "How do insurers determine what is "usual and customary" for all of these surgeries and treatments?"

If you ask your health insurer, they will give one of two answers:

"That information is proprietary (secret)."
"Independent research from all across the industry."

Alrighty then! Independent research!

Guess where the figures really come from? A number-generating company called Ingenix. Ingenix is a subsidiary of ... drumroll please ... United Healthcare!

Makes sense to me. Truly the most brilliant case of cost-shifting ever. Truly the world's worst conflict of interest.

What do these words mean, and why are they so persuasive?

Usual: In accordance with custom or ordinary practice; Normal.
Customary: Based on or established by custom.
Reasonable: Possessing sound judgement; not extreme or excessive.

UCR is the most powerful piece of propaganda that I have ever seen. You couldn't possible dispute the insurer's offer to pay what is Usual, Customary, and Reasonable, could you? Because then you would be abnormal, excessive, and downright crazy.

Who suffers from this massive swindle? The ill and recuperating patient, who believed he was "covered at 80%," who never drilled down to find out what that meant, and who suddenly has to come up with $92,000." And the one who actually did the work, and saved your life -- the surgeon.

You pay more for your PPO. The premiums are higher than the HMO, the deductibles and co-pays are higher. For this, you get an illusion of choice, and the privilege of boing broke if you need to go out-of-network for medical treatment.

Think about it. Patients don't go out-of-network for the fun of it. They go because they are in trouble. Big trouble. Expensive trouble.

Will your entire out-of-network treatment cost more than you could afford to pay in cash? If the answer is "yes," then prepare to write your appeal. In the appeal, you will prove that there is no comparable treatment IN the network, and that the in-network doctors made some very embarrassing mistakes in your case. You will persuade them to sign a contract with your doctor-of-choice, requiring that your insurer pay 90% of BILLED charges.

I do it all the time, and I win them all the time.


If this is news to you, Fight Your Health Insurer and Win should be on your shelf.

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
Old 02-11-2009, 01:29 PM
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Harrison Harrison is offline
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Default The Insurance Intelligencer 2/10/09

Anthem Blue Cross and Blue Shield:
Big, Bad, and Loaded for Bear

My good friend who works for a health insurance company often asks a rhetorical question: "You don't believe that health insurers are the evil empire, do you?"

I never thought about it, until I squared off against Anthem Blue Cross and Blue Shield.

Anthem is big

March 2007: A patient in California tells me that Blue Cross of California has been gobbled up by Anthem BC/BS.

What is going on here?

Anthem is bad

July 2007: I am in Calfornia for a speaking engagement, and I pick up the Hayward newspaper. I see the following headline:

"California didn't try to collect Anthem Blue Cross fine."

In 2006, the California Department of Managed Healthcare levied a fine of $200,000 against Anthem for one unlawful case of "recission." Here is how recission works. When you become expensive (i.e., get sick), Anthem's recission experts get to work. They go back to your original application, and go over it with a fine-tooth comb, looking for an offense/glitch/mistake that would enable them to cancel your coverage.

Anthem did this to 1,770 insured and ill people between 2004-2007, and California imposed an additional fine of $1 million. California has never collected any of this money.

The intrepid reporter from the Hayward Daily Review asks the Director of the Department of Managed Healthcare, "Why haven't you collected any of this money?"

The Director replies that Anthem has the right to contest every one of the 1,770 cases in court. Since Anthem has so many recissions, his department will be tied up in the courts for many years, and no fine will ever be collected.

If you become big enough, you will overwhelm the law with the very weight of your offenses. In other words ... you win.

Anthem is loaded for bear

In September 2008, a very nice gentleman called me from Virginia. He wanted to get to Dr. Sugarbaker for the same lifesaving surgery that I had in 2005.

I went looking for successful lawsuits against Anthem. How did they win, what did they prove, what words did they use?

I happened across Dardinger vs. Anthem of Ohio. I found plenty of language to use. I also found the story of Esther Dardinger.

This was a tort case, on behalf of the estate of Mrs. Dardinger. Yes, the plaintiffs in these types of lawsuits are usually dead. She was forty-nine years old, and she suffered from brain cancer, which had metastized from the breast. Her doctor, who was Director of Neuro-Oncology at the local medical center, recommended that she undergo four treatments of IAC (intra-arterial chemotherapy), which delivers the chemotherapeutic agent directly to the brain.

Anthem approved, and paid for the first three treatments. These treatments dramatically shrank the brain tumors, and improved her symptoms.

When it came time for the fourth treatment, Anthem denied it. All of a sudden, this treatment had become "experimental."

The patient and her husband had no idea what to do. Appeals were filed by doctors, lost, shelved, ignored. All of the interested parties were told to "wait for our letter," "wait until we decide," "wait for our call." This went on for three months.

The final denial letter arrived two days after Esther Dardinger died.

Anthem's position during the trial? "The only mistake we made was paying for the first three treatments." How must it have felt for the widower to hear that?

The court threw the book at Anthem for their "reprehensible" behavior, and slapped them with a $20 million fine.

Apparently, Anthem didn't learn from this case, because they were about to beat me with the same big stick.

Anthem spits in my eye

I will spare you the gothic novel that was my Anthem BC/BS of Virginia case. Suffice it to say that for two weeks they had a half-dozen of us on the ropes, losing sleep, writing letters all night long.

I have won forty-three appeals by assuming that health insurers will pay if I can prove that ...
  • They have paid for it twenty-two times before.
  • Their in-network doctors have no expertise with this disease.
  • Their in-network doctors have made mistakes which could be fatal.
  • Hundreds of peer-reviewed articles document good outcomes.
  • I can find all of their most secret, highest-level insiders -- and their fax numbers.
... they will pay.

Not Anthem. In this case, they adopted a posture of, "We will deny all appeals, regardless of the merits. No approvals, ever. Just try and stop us. We spit in your eye."

First, Anthem tells my helpee that he has to go to an unqualified surgeon who is "in-network." That is standard.

Next, Dr. Sugarbaker's office finagles with Anthem until they approve the hospital ($150,000), but not the surgery ($25,000). This step is standard, and it always gives me a wry chuckle. What use is the hospital without the surgery? Didn't anyone tell Anthem that he is going to the hospital FOR a surgery?

At this point, I deploy the seventy-eight-page appeal, to get Anthem to approve the surgery, and sign the single-case contract with Dr. Sugarbaker's office. Here is where Anthem veers completely off the usual path. Instead of responding to the mountain of proof with a willingness to negotiate, they punish us by taking away the approval for the hospital. The patient is worse off than he was to begin with; he now has nothing.
Anthem justifies "taking back" their approval in two ways:

"We suddenly figured out that this treatment is experimental."
"We never approved it in the first place." (Even though we have copies of the approval letter.)

We supply cases where Anthem paid before. Anthem says that none of our precedent applies, because they those cases were in different states. So, Dr. Sugarbaker's office finds a case in Virginia where Anthem paid. Anthem say that they need "more cases in Virginia." They won't say how many cases would add up to an approval.

Dr. Sugarbaker's office finds two more Virginia cases where Anthem paid. Anthem says, "We will do everything in our power to find the differences between these cases and the current case."

Does this look like a good faith effort to provide safe and effective lifesaving treatment, or a no-holds-barred attempt to deny?
We kept on writing, they kept on spitting.

Finally, Ilse at Dr. Sugarbaker's office managed to maneuver Anthem into reinstating the approval for the hospital. The patient had to pay out-of-pocket for the surgery.

People say, "How can they do this? Can't you sue them?" Sure, go ahead and sue them ... but you probably won't win unless you're dead. Or should I say until eight years after you die, because that is how long it will take to wend its way through the courts.

Did they persist in denying this treatment, with no good reason for doing so? Was it deliberate? Was it evil? I leave it for you to judge. All I know is that it almost did me in.

The patient in question had his surgery with Dr. Sugarbaker today. I think back, as I always do, to my own surgery in 2005. I trust that, in four years, he will be as healthy as I am today. That he will be transformed by the experience, as I was. And that he will know, as I do, the sweet satisfaction of helping and being helped.

Happy and peaceful Insurance Warrior-ing,

Laurie Todd

Give a copy of my book to someone you care about today.
"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 03-07-2009, 06:29 PM
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Harrison Harrison is offline
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Lightbulb The Insurance Intelligencer - 3/9/09


The Insurance Warrior is Coming to CHICAGO!

May 15-16

Registration is only $75 for the entire conference. I will be giving two presentations, and a Winning Appeal Workshop.
Any questions, contact

The Insurance Intelligencer - 3/9/09

The First Three Things to Do

Over the past four years, I have talked to hundreds of people who discover, one day, that their health insurer doesn't plan to pay for their treatment. There are many reasons for this, as health insurers have developed countless ways not to pay.

By the time people get around to calling me, they have usually galloped off down the wrong path, and lost at least one appeal. They have no concept of why the insurer is really denying, or how to meet that denial head-on. They try to prove that their treatment is not "experimental," without having any idea what the insurer means by this.

They are fighting the wrong battle, with the wrong ammo, on the wrong hill. Meanwhile, the insurer is rolling right over the top of them, on to victory, with not a dent in their armor.

What People Do

When the insurance won't pay, people call for help. Who do they call?
  • The insurance company
  • The Insurance Commissioner
  • A lawyer
  • The media
Call the insurance company for help, because the insurance company doesn't want to pay? They are going to make themselves pay? I believe that people pursue this non-sensical approach because they are afraid, and they need to believe that the insurer is there to help them. Our lives are on the line, and we want to believe that we are in caring hands with our insurance company.
The name of the insurance company will make you feel safe -- "Neighborhood Health Golden Rule Care Choice United Insurance Company." The titles of the employees will make you feel all warm and fuzzy -- "Customer Care Rapid Response Resolution Team." Their job is to calm you down, make you wait for their letter, and to keep you away from decision-makers at all costs.

You aren't safe. They aren't planning to pay, and you won't move them one inch. All that you will do is raise your blood pressure.

Call the Insurance Commissioner? First, all most Insurance Commissioners do is take a complaint, and get back to you in a few months, saying that they looked into it. Insurance Commissioners have no power, health insurance companies laugh at Insurance Commissioners.

Call a lawyer? Guess why lawyers aren't interested in denial of care cases ... there is no money in it. No damages. If you win a denial of care case, all you get is your treatment.

Will the media intimidate an insurer into paying for your treatment? It would have to be a pretty massive media blitz, including the national news and the Today show. Is your insurance company going to be reading your local paper, or watching the local news, and suddenly decide to pay? Could happen, has happened. However, there is so much bad press out there about many of our insurance companies. It doesn't appear to bother them in the least. What then should you do?

ONE: Find the Medical Policy Statement

When the insurer denies your treatment, you need to know what is their official policy about it. Once you have the Medical Policy Statement in your hand, you can start to disprove it.

You think that you understand your coverage (i.e., your contract with the insurance company), because you have read your benefits booklet. Wrong. That contract is modified and limited by a body of hundreds of Medical Policy Statements, which are sometimes called Treatment Guidelines. You may think you have a certain amount of coverage, but you have no coverage if you happen to need one of the treatments referred to as "investigational" or "not medically necessary" in the Med Policies.
Where do you find the Med Policies? On the insurance company website, under the section for physicians and medical providers. Yes, you have graduated. You now look where the doctors look.

Each Med Policy states their position on a treatment, then offers ten or fifteen sources to back up their position. If you don't like their position, start digging into these articles/associations/groups etc. that they use as proof. You will be amazed to see that most of it is useless, outdated, doesn't prove their point, or is generally a carton of hot air. Drill into the Med Poliicies, because it is these documents that the insurers are using to deny your treatment.

TWO: Study the definitions

Do the benefits booklet and the Med Policies constitute your complete contract? No way! Your coverage is also limited by the "definitions." You thought that those definitions at the back of the benefits booklet were just there to help you decipher the insurance lingo? Joke's on you, these definitions are the pillars that there denials stand on. And the only way to reverse the denial is to knock the pillars out from under them.

If your treatment is denied as "experimental," please don't run around like a chicken, trying to prove that the treatment is not experimental based on what YOU think it means. Find the definition, argue that your treatment meets and exceeds every requirement, and make it the centerpiece of your appeal.

THREE: Understand the appeals procedure

People often call me saying, "I lost my first two appeals, what should I do?" I ask, "What further appeals procedures are available to you?" Invariably, the say, "I don't know?"

It's your appeal, you've lost two of them, and you have no idea what your insurer's appeal procedures are?

If you plan to approach this battle strategically, the first thing that you need to know are the rules of engagement.

Whatever you do, don't simply sit down and start writing an appeal. Insurance Warrior-ing is a new profession for you. That means that you don't know how to do it yet. If you decided to become a brain surgeon, would you just march into an operating room and start hammering on somebody's head? First, we study. Then, we research. Next, we plan our strategy. Then, we write our appeal.

Put yourself through basic training, learn the rules of engagement, choice the right weapons and learn how to use them. Know your enemy. Keep a cool head. And you will emerge victorious.

Happy and peaceful Insurance Warrior-ing,

Laurie Todd

P.S. If any of this is news to you, perhaps my book should be on your shelf.
"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 05-26-2009, 10:46 AM
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Hot off the presses!
It's a CD!

"The Sample Appeal: More Insurance Warrior Wisdom"

Check it out:


All Plan Language is Misleading

I recently had a call from a newspaper reporter, asking for information for an article about "misleading plan language."

The reporter was not looking for my opinion. She assumed that I offer a service sorting out people's medical bills -- a type of patient advocate, or a reimbursement specialist. She wanted me to provide the names of several patients who had gotten into trouble because of "misleading plan language." Her request made me reflect on both what I do, and on what role misleading plan language plays in the larger world of health insurance.

First, let me say that I do not offer a service. I speak, I teach, I write on insurance topics. I fight the occasional appeal, but only if it is difficult, compelling, and lifesaving.

Medical bills give me a big headache; I want no part of them. That is why I write powerful appeals up front -- so that there will BE no medical bills.

The reporter's question was based on the assumption that a benefits booklet is a good faith effort by the insurer to explain your coverage, and the only problem is that a few phrases might be misleading.

People, please. I am asking for a paradigm shift. The entire purpose of a benefits booklet is to mislead, and all plan language is misleading.

What is a benefits booklet?

My plan documents?
A summary of my coverage?
An explanation of what my insurer will pay?

Think again. The benefits booklet explains the medical services covered by your insurance plan. It just doesn't include all of the circumstances under which they will NOT cover them.

In my opinion, that is misleading.

What is the purpose of a benefits booklet?

To make you feel well-covered and financially secure, while shifting more and more of the medical expenses to you.

It's a tricky business, one which requires very misleading language.

Last year, a friend asked me to review three different insurance plans. She needed to decide between them, and she figured that the Insurance Warrior could shed some light on the situation.

It has been twenty years since I chose a health insurer, or studied a plan summary. Twenty years ago, benefits booklets were pretty straightforward. As I examined these three insurance plans, I was amazed to see how complex, opaque, and generally misleading such insurance documents are nowadays.

Dig a little more deeply into any plan documents, and you will see all of the ways of not paying that are built into the plan language. Powerful denial words are mixed in with harmless coverage words.

I know a lot about how insurers use words to deny treatments. I was amazed at how insurers are now using the same words up front -- to lay the groundwork for not paying later.

They give with one hand, and take with the other.

How does the language mislead?

The biggest-ticket item in anyone's insurance plan is prescription drugs. Let's look at the Plan Summary of Acme Insurance, and see how the language misleads you into thinking that you have coverage, when you don't.

The misleading language starts with the name of the plan: Acme Insurance Comprehensive Plan. Sounds like it covers just about everything, doesn't it?

The Comprehensive Plan is the most expensive. One of the extra benefits that you are paying for is prescription drug coverage. And yet, when you put all of the language together, you are not covered at all. What could be more misleading?

Let's count the ways in which Acme shifts the prescription drug costs to you:
  • You have a yearly maximum of $2,000 -- just for prescription drugs. Those of you who have had cancer know that you will use that up in a week. Avastin, a cancer drug, costs about $13,000 per month. Erbitux, a monoclonal antibody also given for cancer, costs in the neighborhood of $62,000 per month. You are exposed, you have no coverage.
  • In order for Acme Insurance to pay for it, a drug must be on the "formulary." Guess which drugs are not on the formulary? The most expensive ones, and the most commonly prescribed ones.

    How can you know ahead of time what illness you may get, and whether the drug that treats it will happen to be on the formulary? The formulary shifts the largest burden of drug costs to you, while giving the illusion of coverage.
  • In the fine print, Acme states that they have a "closed formulary." Do you know what that means? On the Acme website, it says, "The closed formulary provides value." Talk about your double-speak. In a closed formulary, the insurer only pays for the most inexpensive, generic form of any drug. Value indeed -- to the insurer, not to you.
  • The drug must be on the formulary, you only get a pitiful $2,000 per year. Guess what else? Acme only pays 50% for any and all prescription medications that they do cover.
  • But it gets worse. There are three "tiers" of drugs. For the more expensive drugs that Acme has generously included on their formulary, they don't pay even 50%. For these "first tier" drugs, they pay only 30%.
  • Oh, and one more thing. Acme can deny any and all prescription drugs that you might need, whether or not they are on the formulary. All they have to do is call them "not medically necessary." Not medically necessary according to whom? According to the Medical Director of the insurance company.
Sometimes I wonder why they bother. Why don't they just say, "We don't cover prescription drugs"? Because people want prescription drug coverage. Or at least something that looks like coverage.

Know that all plan language is misleading. But also know that all of the forty-four appeals that I have won have been for totally out of benefit, not covered, out of plan services. And yet have always paid, if I lean on them in just the right way.

When it comes to health insurance, everything is negotiable. But only if you see through misleading plan language, and turn it to your advantage in your appeal.

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
Old 06-25-2009, 10:45 AM
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The Insurance Intelligencer

What is the matter with health insurance?

I can put it in three words: Insurance. Drives. Care. A private, for-profit corporation gets to decide whether or not they will pay for lifesaving treatments, which are always astronomically expensive.

Make no mistake about it -- health insurers are for-profit businesses, no matter what they call themselves. It is the job of a business to minimize operating expenses, and to maximize profits. That is what a business does.

We would not expect any other business to care about our lives, or about our quality of life. We would not agonize over the fairness or unfairness of any other business's decisions. Why are we so shocked and disappointed when we discover that Acme Insurance is not the least bit moved when we tell them, "But, without this treatment, I will die"?

Because of the propaganda.

I am not outraged that a bureaucracy makes unfair decisions, or that a business doesn't value lives above profits. That's life in the free-market economy. What does rile me up is the vast body of propaganda, designed to make us believe that they do.

The website with photos of happy, healthy insured people. Riding their bicycles, gazing up at the name of the insurance company: Neighborhood Healthy Choice United. You know, the insurance company that will refuse to pay for your child's brain surgery. The same insurance company that, if you need out-of-network treatment for breast cancer, will bill you for an extra $200,000 beyond what they consider to be "reasonable and customary." Some choice.

We have lived under this insurance-driven system for forty years -- so long that we accept it without question. We cannot imagine any other way.

In what world is it acceptable for a health insurer to pay for a lifesaving treatment for a hundred cancer patients, then to turn around the next day, and deny the same treatment as "Experimental"?

In what world is it acceptable for a health insurer to have the sole, unfettered power to decide how much they will pay for medical treatments? To keep this payment information secret. And to generate the numbers themselves.

In what world is it accepatable for a health insurer to deny a cancer patient the one treatment proven to prolong his life -- a treatment which costs $50,000 -- while spending $1.5 million on routine in-network treatments and surgeries, with no scientific proof that they will prolong his life, or give him any clinical benefit whatsoever?

Not in my world.

Let's see a few of the ways in which insurance drives medical decisions.

Your doctor: The gatekeeper

Your Primary Care Physician looks like a doctor. He wears a white coat. He asks the questions that doctors ask.

As you sit in his office describing your symptoms, you assume that Dr. PCP's job is to discover what is wrong with you, find the best treatment for your condition, and order the treatment for you.

Think again. The Primary Care Physician's job is to be the gatekeeper. In other words, to control access to medical services. A job which fulfills the primary goal of a business, which is to control operating expenses. Sounds like an insurance job, not a medical job.

If the best treatment for you does not happen to be offered in the insurer's network, it is not his job to find it, to offer it, or even to know about it.

This is one of the deeper problems of insurance-driven treatment.

I have a late-stage cancer. There is one out-of-network treatment that could rid me of the cancer, and give me a 70% chance of non-recurrence. This treatment has been performed, studied, proven for thirty years. In what world is it acceptable for the Chief of Oncology to say to me:
  • There is no treatment for your disease.
  • If there were a treatment, they wouldn't pay for it.
  • If you had this treatment, you would be disabled.
  • I wouldn't send my mother for this treatment.
Ignorance? Acceptable. Because, in the insurance-driven world, if we don't have it in-network, it doesn't exist.

Lies? Acceptable. If he champions an out-of-network treatment for me, it will be a monumental hassle for him, and they won't pay in the end. My current local doctor is smart, diligent, respectful, and hard-working. However, even he is infected with insurance-think. Whenever I bring him new material to read about the treatment which saved my life in 2005, he says, "Of course, your cancer is so rare ... we won't see any more cases of it."

The horrifying presumption is that it is our job as insurance medical providers to treat the lowest common denominator of diseases and conditions. Why would we go out of our way to learn about a "rare" disease?

I belong to a very small HMO. I am not privy to medical records. I personally know of ten members of the HMO who have been diagnosed with my type of cancer. One of them was the wife of an HMO doctor. She was mistreated there for three years, until a friend happened to tell her about me. I talked to the patient, and to her husband the rheumatologist. They called my expert surgeon, but it was too late -- her disease was too advanced. She has most likely died by now.

This disease -- appendix cancer -- may have been rare back in 1962, but it is not rare now. However, my doctor will always see it as rare. Why? Because there is no treatment available in the network.

Even if you have the most common cancers, the best, most effective, most cutting-edge treatments may not be available in-network. As a matter of fact, they probably won't be, as insurance companies are very slow to approve new treatments. Like thirty years slow. Will your doctor know about them? Will he tell you about them?

What treatments your doctor offers are driven by insurance.

Denials and reimbursement strategies: How they shape medical care

We know that denials allow the insurer to not pay for that treatment, in that particular case. Of all people who receive insurance denials, only one-half of one percent ever appeal the decision.

If the patient is ambitious enough to appeal, and get the denial reversed -- still no problem for the insurance company. They will simply reduce reimbursement on the other end. Once the lifesaving treatment has been performed, Acme Insurance will delete codes, bundle codes -- whatever it takes to reduce reimbursement to pennies on the dollar.

Don't worry about Acme Insurance. Even if you make them pay for non-routine payments, they won't pay much.

We see that the insurer has many ways of reducing their operating expenses: Delay, deny. And, when you have to pay, don't pay much. Reducing expenditures is a perfectly natural practice for a for-profit business.

However, there are larger implications. Insurance drives care.

There is a perfectly good treatment for liver tumors called Y90 radioembolization. It involves introducing radioactive microspheres directly into the liver, via the hepatic artery. This treatment improves symptoms and prolongs life for people with primary liver cancer, and liver metastases from breast cancer, colon cancer, ocular melanoma, and neuroendocrine tumors.

Recently, a large medical facility had to stop offering this treatment for most cancers. Insurers vigorously denied it, or paid so little for it that the provider was losing about $10,000 per treatment. They couldn't even cover the cost of the microspheres.

Consequently, people won't be getting this treatment anymore at this medical center. Soon, other medical centers with have to stop offering it, too. Unless, of course, they bill Medicare enough to make up for the appalling shortfall from private insurance.

Is this acceptable to you? What if your mother needs this treatment, or she will die? If she is denied, I can write an appeal for her. However, if the treatment is no longer available, there is nothing that I can do.

What would the Insurance Warrior do?

I usually refrain from pontificating about the larger insurance issues. However, more and more people are asking, "What would you say, if Barak Obama asked you what to do about health insurance?"

First, Barak Obama should ask me about health insurance. Not only have I thought deeply about these issues, but I see up close and personal how insurance company decisions play out in the lives of real doctors and patients -- including myself.

As it stands now, the insurance company gets to decide whether or not we will get the astronomically expensive lifesaving treatments that the insurance company is going to have to pay for. This is insane.

Peer-to-peer reviews are performed by the same Medical Director of the insurance company who denied the treatment in the first place. He is not a peer, and it is not a review. The last independent review that I got mixed up with was for a technologically complex cancer surgery. The "independent review organization" was a chiropractor with a post office box in Lubbock, Texas. With an independent review, there is no accountability, no input, no recourse, and no oversight. They could uphold 100% of insurance denials, and nobody would ever know.

No matter how much you pretty it up, and try to give the illusion of due process -- this is the world's worst conflict of interest.

I would take both the research about which treatments to offer, and the decision on when to approve them -- out of the hands of the insurance company. Most of the treatments denied by insurance companies have more scientific proof of their efficacy than the treatments routinely offered by the insurance companies. They have no track record in making good decisions about treatments, it needs to be taken out of their hands.

A truly independent entity would be tasked with finding the treatments most likely to give a good outcome -- regardless of whether the doctor or facilty was contracted with anybody's insurance company.

Then, so that all doctors don't quit the profession, and all medical facilities don't go broke -- I would task my independent entity with setting fair reimbursements for medical services. I would also outlaw fraudulent and deceptive practices designed to unfairly reduce reimbursement.

We don't expect insurance companies to operate at a loss. Why should we expect the medical providers who are saving our lives to do so?

Give Barak Obama a call. I am eager to talk to him about health insurance.

Happy and peaceful Insurance Warrior-ing,
Laurie Todd

My new book is here! It's a CD!
It answers all of your questions about how to write an appeal!
It includes a sample appeal for you to edit and use!

"The Sample Appeal: More Insurance Warrior Wisdom"

SAVE $5 on the book/CD set.

"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 07-20-2009, 01:52 PM
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Default The Insurance Intelligencer 7/20/09

The Insurance Intelligencer

Calling your insurance company: The Mad Hatter's Tea Party

Ken recently bought my book and CD. He has studied these materials, and he is writing an insurance appeal.

Ken told me that he couldn't find any executives at Acme Insurance to copy on his appeal. I searched and found the names of the President, Medical Director, and Vice President of Quality Assurance, and sent them to him. I explained how to google, then told him to go out and find personal contact information for them, so that he could fax his appeal to the Medical Director in the middle of the night.

The next day, Ken emailed, "I called Acme Insurance, and they would give me the Medical Director's personal fax number."

Ken was doing a lot of work, and paying attention to the details. However, he was missing the whole point behind the details.

It is the insurer's job not to pay. And your job to make them pay.

The insurer is not going to help you win your appeal. They aren't going to be eager to give information over the phone that will help you to win your appeal.

Back to Basics

Laurie's Rule #1: The only reason to call your insurer is to find out where to write to.

Have you ever tried to solve anything with your insurance company by calling them on the phone? I will tell you what happens:
  • They won't give you their last names.
  • If somebody gives you a call-back number, it won't work.
  • Each person you talk to has a different answer to your question.
  • You won't get any higher on the food chain than Customer Service
Excuse me ... they don't call them Customer Service anymore. They call them "Customer Care," because they do want you to know that they care.
Customer Care won't be able to find a copy of your contract, and they won't know how to find your benefits booklet. They will be eager to put you in what I call "Waiting Mode." Wait for our call, wait for our letter, wait for our decision. Wait as long as we tell you to wait. Wait until you are either dead or all better, and we don't have to deal with this pesky problem anymore.

You will talk to many people. My favorite case of Insurance Phone Madness comes from Florida. Camille was fighting hefty hospital bills after the fact; this is called a "grievance." Sort of makes us sound like whiners, doesn't it? Just pay your bills, and stop giving Acme Insurance all this grief! She kept a list of every employeee that she talked to at Acme Insurance. What she asked, what each one said.

Camille talked to forty-eight people at Acme Insurance. She was no closer to winning her case than she was to begin with; she had gotten nowhere.

The only reason why talking to forty-eight people wasn't a complete waste of time? Because I took the entire list, and made it the centerpiece of her written grievance. I quoted each of the forty-eight people -- each telling her how they were going to solve her problem, each not doing anything. Each making promises, each breaking promises.

The entire Mad Hatter's Tea Party of phone calls looked very embarrassing in her grievance letter. It took Acme a couple of weeks, but they decided to pay.

Do they do this on purpose?

People often ask me, "Do insurers discourage, dissuade, dissemble, delay and deny us on purpose?

I don't know. And it doesn't matter. All that matters is that you not waste your precious energies on the phone with the insurance company. Do your research, line up your facts, send your appeal to the correct decision-makers.

By doing this yourself, you do not engage in the losing exercise of calling your insurance company on the phone.

How do I find the Medical Director

And so, we end where we began. How do we find personal contact information for the Medical Director of Acme Insurance?

Acme Insurance will do everything they can to keep his name and contact information from you. He is the highest medical decision-maker at the insurance company! He must be protected from the likes of us -- insured people, with our nasty, troublesome issues!

Here are some real examples of what Customer Service says, when you call on the phone, and ask about the Medical Director:
  • We don't know who we work for.
  • We have no Medical Director.
  • The Medical Director is on vacation.
  • We dare not speak his name.
People. They don't want you to have this information. Google the Medical Director, and find him yourself. Here is how I do it:
  1. Study the Acme website. Be persistent, spend an hour if you have to. Look for the "Leadership Team." If there is a search feature, search for "executives," "medical director," "or "chief medical officer." Get a name and title.
  2. If you can't find him on the insurer's website, google "medical director acme insurance 2009," "medical officer acme 2009," or "vice president acme insurance 2009." I include the current year, so that I don't have to wade through a dozen past medical directors.
  3. When you have the current Medical Director's name, google, "john smith acme insurance phone," "john smith acme fax," or "john smith acme insurance email." You may have to sift through six pages of search results, but you will find your man.
If Acme Insurance goes to that much trouble to keep you from the President, the Medical Director, and the Vice President of Quality Assurance ... you know that access to them is pure power.
That is why I invite you to be as relentless as I am, to find their personal information, and to fax them a copy of your appeal.

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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