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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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  #11  
Old 05-24-2007, 06:21 AM
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CindyLou CindyLou is offline
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Thank-you Laurie. Welcome aboard! We need you and are grateful for any and all input you can bring our way. Meanwhile, I'll be lining up to buy your book on your website. I am not done with my fight yet against HealthPartners! (btw, people, steer clear of HealthPartners at all costs...they completely suck)
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CindyLou
bicycle accident 6/19/01
2 compression fractures, T12, L1;
vertibroplasty @ above levels, 9/15/01
4/06 hip labral tear repair
4/07 Lumbar ProDisc replacement by Dr. B., 3 levels; L3-6
7/2/08 ALIF of L6-S1
7/30/08 Removed bone cement.
8/7/08 Diagnosed with pulmonary embolism, double pneumonia, collapsed left lung, pleurisy, pleural effusion.
3/10/09 right SI Joint Fusion; seeing light at end of tunnel, for first time in 8 years!!
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  #12  
Old 05-24-2007, 08:24 PM
The Insurance Warrior The Insurance Warrior is offline
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A New Tactic

I have already learned something from helping with an ADR case ... the health insurers have adopted a new tactic in their efforts to deny. Keep an eye out for it.

Bear in mind, I am new to the ADR world. So ... I ask some naive questions. The person that I am helping tells me that she is requesting a "second level" disk. I say, "Wait a minute. They paid for it before. In the cancer world, if they pay for it before, we can generally make them pay for it again."

"I did point that out to them," she replied, "They told me that, when they approved it before, they paid by mistake." BY MISTAKE??? This is a new one on me ... the I.W.'s infallible gut-o-meter told me that what we have here is a brand-new objection.

Three days later, I was called in on a rare cancer case. Person needed surgery, insurer didn't want to pay for it. Medical Director of Acme Insurance calls the expert surgeon's office, asserting that the surgery is experimental. Expert surgeon's P.A. says, "Acme Insurance, United Healthcare, Aetna, Cigna ... all of them have been paying for this for years." Medical Director replies, "Acme Insurance would never pay for this. If we ever paid for it, we paid by mistake. You must have given us the wrong CPT codes." Right. This surgery plus hospital costs about $200,000. They goofed up and paid for it without meaning to.

Picture this. Bean counters at the insurance company sitting around, discussing policy: "These patients are starting to talk to each other. They are presenting us with lists of cases where we have paid before. We need to find some way to counteract this. Let's just say we paid by mistake!" Apparently the memo went out industry-wide.

Here is how I handled it. I wrote a letter for these folks -- in the patient's voice, of course. I quoted every absurd, untrue, insulting thing the Medical Director said to the expert surgeon's office. Dragged the whole stinkin' conversation out of the closet. As a cherry on the sundae, I added a few more instances where they told untruths, sent the patient to a local surgeon with no experience who would surely have killed him, etc.

I had them fax it to everyone from the Medical Director on down, everyone who is anyone at the employer, and so on.

I have shamed and embarrassed customer service people, case managers, and many doctors who told untruths or denied care, but never a Medical Director. My letter (from the patient) should hit the fan tomorrow. The surgery is scheduled for June 4. The usual last-minute cliff-hanger.

If somebody at the insurance company says something to you which is absurd, ridiculous, untrue, or contrary to your benefits booklet ... people, that is your gold nugget. They have just given you the most powerful ammo you could have. You are going to quote them in your letter -- word-for-word.

The whole idea with these appeals is to make yourself sound so dangerous, such a hot potato, that they pay just to get rid of you.

It is really quite strange. Here I am writing all of these letters in the voice of the patient. Or else, patients are using the words from the book. Hopefully it takes a few years before insurance companies start scratching their heads and wondering how all of their insureds suddenly got to be such good writers.

So ... if your insurer says that they paid for this before "by mistake," quote them in your letter. It is a ridiculous thing to say. Also, supply a list with patient names, surgeon's names, and surgery dates where they have paid for this before. Make it personal, not just a list of cases that have been paid. Surely four different surgeons' offices couldn't all have submitted the wrong codes.

I would have fun with it. If somebody told me that over the phone, I would calmly ask, "So ... you're telling me that Acme Insurance has paid by mistake for many surgeries costing in excess of $50,000? MAY I QUOTE YOU ON THAT?"

Go get 'em

Laurie the I.W.
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  #13  
Old 05-25-2007, 07:23 AM
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CindyLou CindyLou is offline
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Laurie, I like where you're going w/ your strategy tactics. My problem is my husband's employer is privately owned and self-insured, so basically HealthPartners is just acting in an administrative capacity, it appears, under the guidelines of our 2007 health coverage summary plan. Which btw, has still not been finalized or signed by the company head! Every time they deny my appeals, they remind me "it may be helpful to note that all of HealthPartners' coverage policies are available on our web site at www.healthpartners.com, or by calling Member Services at_______." But, the bitch is, when I go to the website and enter my password, it tells me my coverage policy is not available. Then, I call the member service folks, and they read to me what is covered or not! I don't have a copy in my hands, because it's not signed yet!
For example, I quote from my latest final denial: "Your plan excludes coverage for services that are considered investigative. (this is their only answer every time they deny me..investigative) Although NAME OF EMPLOYER has not yet finalized its 2007 Summary Plan Description (SPD), we anticipate that the benefit provisions, when finalized, will read as follows. Under the heading, Services Not Covered, your SPD reads in part: 2. Procedures, technologies, treatments, facilities, equipment, drugs and devices which are considred investigative, or otherwise not clinically accepted medical services." When they sent my appeal for further review to their medical directors, they said,(in same denial letter as above) "this reviewer confirmed that Artificial Intervertebral Disc Replacement is considered investigative at this time. Additionally, the reviewer asserted that the FDA approved labeling of the ProDisc states that the safety and effectiveness of this device has not been established in patients with the following conditions: pregnancy, morbid obesity, two or more degenerative discs, spondylolisthesis greater than 3 millimeters, or two or more unstable segments. The ProDisc is currently required to undergo a Post Market Study to evaluate its long-term safety and efficacy." I do fall under "two or more degenerative discs" category, but I thought the FDA had approved the ProDisc for 2 levels. I happened to need 3 levels, so went to Germany. But my point is, all of these long winded denial letters, time after time, and yet "the company has not yet finalized its 2007 Summary Plan Description, we anticipate that the benefit provisions, when finalized, will read as follows." How crazy is that? I am being denied on what they anticipate the plan to say, when finalized!! Sorry for the long description. Any advice?
__________________
CindyLou
bicycle accident 6/19/01
2 compression fractures, T12, L1;
vertibroplasty @ above levels, 9/15/01
4/06 hip labral tear repair
4/07 Lumbar ProDisc replacement by Dr. B., 3 levels; L3-6
7/2/08 ALIF of L6-S1
7/30/08 Removed bone cement.
8/7/08 Diagnosed with pulmonary embolism, double pneumonia, collapsed left lung, pleurisy, pleural effusion.
3/10/09 right SI Joint Fusion; seeing light at end of tunnel, for first time in 8 years!!
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  #14  
Old 05-25-2007, 07:28 AM
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CindyLou CindyLou is offline
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Oh boy. Maybe I should have left the companys' name off. I don't know how to edit yet. Harrison, could you edit that name out, please? Thanks. Cindylou
__________________
CindyLou
bicycle accident 6/19/01
2 compression fractures, T12, L1;
vertibroplasty @ above levels, 9/15/01
4/06 hip labral tear repair
4/07 Lumbar ProDisc replacement by Dr. B., 3 levels; L3-6
7/2/08 ALIF of L6-S1
7/30/08 Removed bone cement.
8/7/08 Diagnosed with pulmonary embolism, double pneumonia, collapsed left lung, pleurisy, pleural effusion.
3/10/09 right SI Joint Fusion; seeing light at end of tunnel, for first time in 8 years!!
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  #15  
Old 05-25-2007, 09:34 AM
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Harrison Harrison is offline
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Cindy, see the little pencil eraser in the lower right corner of your posts? That's your ticket to editorial bliss...
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"Harrison" - info (at) adrsupport.org
Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
Founder & moderator of ADRSupport - 2004
Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
Creator & producer, Why Am I Still Sick? - 2012
Donate www.arthropatient.org/about/donate
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  #16  
Old 05-25-2007, 10:29 AM
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Terry Terry is offline
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CindyLou:

Being an impartial, hostile against insurance providers (they provide money to their shareholders) type person, I can say things that you may not be able to. Take www.healthpartners .com insurance, which is indicative of the managed care industry that, unfortunately, started out in Minnesota. Group Health, HealthPartners, Metopolitan Clininc of Counseling (MCC), Share, etc. are managed care industries that operated as for profit organizations. Denying care is what they do best. They deny Substance Abuse and mental health treatment like it's going out of style.

CindyLou----If your husband is in management and that high up in the company, someone can call and have them review your file to determine medical necessity. Mine got denied twice and I signed an agreement that wiped out the lien Blue Cross had against my lawsuit by agreeing to not appeal my denial. The insurance salesperson who sells us our Blue Cross insurance for our company is on our board of directors and made the call on my behalf to have them review my case. They paid it in full.

Someone from your husband's upper management can call and threaten to send the company's business elsewhere if there is an unfavorable outcome from the insurance. If the company is self-insured like you say, they should be taking care of their own.

All-in-all my humble and non-biased opinion.

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
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  #17  
Old 05-25-2007, 10:50 AM
The Insurance Warrior The Insurance Warrior is offline
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Hi CindyLou --

In order to offer specific advice on why your appeals have not succeeded, I would have to see the appeals. Remember, the intention of a written appeal is to intimidate, not to prove nor to inform.

Regarding the FDA approval, and what qualifications and caveats there are on it ... we will have to get some enlightenment from someone here who is conversant with it. Let me just say that, in the appeals that I have participated in where the insurer said that some procedure was “not FDA-approved,” we ignored it, listed a lot of similar cases where they had paid, a lot of peer-reviewed articles, letters from in-network doctors, made ourselves sound like scary lawyers, and made them pay anyhow. I acknowledge the insurance company objections, but try not to get too mired down in them.

A word or two about “self-funded” plans. We are seeing more and more of them these days. In a self-funded plan, a “third party” administers your benefits, which are paid out of the employer’s bank account. Why the employers go for this option, I do not know. Perhaps they go into it believing that they will be able to better control costs themselves. Some of the terrible consequences that we have seen with self-funded plans:

1. A few employees come down with cancer, and the employer runs out of money before the end of the fiscal year.

2. Employee comes down with cancer, “third party” doesn’t want to pay, employer doesn’t want to pay. Now, you are locked in mortal combat with an insurance company AND your employer ... all while fighting cancer.

3. With both company H.R. department and shadowy “third party” mixed up in it, it is almost impossible to nail down who the decision-makers are.

There are, however, great benefits in these self-funded plans ... for the insurance company. First, is this third party payor a real insurance company, or just an administrative entity? If the third party is not an insurance company, then, in the legal sense, your health insurance is NOT CONSIDERED TO BE INSURANCE. In other words, you cannot appeal to the Insurance Commissioner in your state for help. The self-funded plan is not subject to state law regarding health insurance. Your only protection is the applicable federal law, which is HIPPA. Guess how long HIPPA allows for a determination to be made if there is a dispute or appeal? 120 days.

However, if the third party is a real insurance company – not just an administrator – they will still be subject to the state’s Insurance Commissioner, and state law.

Now to your question of “the employer never gets around to finalizing the insurance plan, and the ‘third party’ will never give me a copy of it.” Honey, I would put all of that in your appeal. I don’t have time to Google all this today, but I believe that, if you call your state’s Insurance Commissioner, they will be able to tell you that there is plenty of law compelling your insurer to provide/disclose total current info about your plan. If I remember HIPPA correctly, they also require this. Remember, these appeals are meant to intimidate, in the legal sense, and leap over specific objections. If I had nothing else to work with, I would seize on this as the centerpiece of my letter to the employer/insurer.

Not that it really matters, because the new plan will, of course, deny again based on them calling the procedure “investigational.” However, I believe that you might be able to make a compelling case about them not providing current coverage info, not having a signed policy in place, etc.


Torpedos away,

Laurie the I.W.
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  #18  
Old 05-26-2007, 10:15 AM
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CindyLou CindyLou is offline
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Thank-you Harrison!
__________________
CindyLou
bicycle accident 6/19/01
2 compression fractures, T12, L1;
vertibroplasty @ above levels, 9/15/01
4/06 hip labral tear repair
4/07 Lumbar ProDisc replacement by Dr. B., 3 levels; L3-6
7/2/08 ALIF of L6-S1
7/30/08 Removed bone cement.
8/7/08 Diagnosed with pulmonary embolism, double pneumonia, collapsed left lung, pleurisy, pleural effusion.
3/10/09 right SI Joint Fusion; seeing light at end of tunnel, for first time in 8 years!!
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  #19  
Old 05-26-2007, 10:37 AM
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CindyLou CindyLou is offline
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And thank-you Laurie and Terry. The company does use HealthPartners only in an administrative capacity, so I cannot go to the state level. Don't think federal is the route either, like you said. I think you nailed it Laurie. Intimidation is my best approach w/ leverage of "no finalized 2007 Summary Plan" yet. And maybe include the comment the owner of co. said to my husband in my husband's private office, when he came to ask how I was: "you know, I could pick up the phone and just tell HP to pay for it." Then obviously changed his mind after meeting with his HR hire who advised him against it. (btw, we found out his top HR person who helps decide what is covered and what is not, HAS HERSELF COVERED UNDER HER HUSBANDS' BENEFIT POLICIES!) Terry, I agree...they should take care of their own, especially since my husband is one of the top exec's and has been with the company for 16 years. My fight is not over!
__________________
CindyLou
bicycle accident 6/19/01
2 compression fractures, T12, L1;
vertibroplasty @ above levels, 9/15/01
4/06 hip labral tear repair
4/07 Lumbar ProDisc replacement by Dr. B., 3 levels; L3-6
7/2/08 ALIF of L6-S1
7/30/08 Removed bone cement.
8/7/08 Diagnosed with pulmonary embolism, double pneumonia, collapsed left lung, pleurisy, pleural effusion.
3/10/09 right SI Joint Fusion; seeing light at end of tunnel, for first time in 8 years!!
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  #20  
Old 05-26-2007, 01:07 PM
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CindyLou CindyLou is offline
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Posts: 627
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Getting armed! Just ordered your book, Insurance Warrior. Will wait eagerly for it.
__________________
CindyLou
bicycle accident 6/19/01
2 compression fractures, T12, L1;
vertibroplasty @ above levels, 9/15/01
4/06 hip labral tear repair
4/07 Lumbar ProDisc replacement by Dr. B., 3 levels; L3-6
7/2/08 ALIF of L6-S1
7/30/08 Removed bone cement.
8/7/08 Diagnosed with pulmonary embolism, double pneumonia, collapsed left lung, pleurisy, pleural effusion.
3/10/09 right SI Joint Fusion; seeing light at end of tunnel, for first time in 8 years!!
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