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Old 05-20-2007, 10:38 AM
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Default The Insurance Warrior (Read-only topic)

As you all know, medical insurance issues about within our community. Insurance companies wield considerable influence in our personal lives, on Capitol Hill and especially with hospitals. Most of us here have gone to bat (battle?) against insurance companies for coverage for our surgical procedures. It’s terrible, and I fear, getting worse.

Enter the “empress of insurance appeals,” or more popularly known as “the insurance warrior,” Laurie Todd. Her expertise is shaped by her own personal experience -- and successes -- as a cancer patient; she now helps patients from all walks of life win coverage for their treatment. Her record to date helping patients is flawless – and I’ve warned her about the lackluster results we patients have experienced! Nonetheless, here are some ideas for patients to consider:

1. Read the book she wrote: Fight Your Health Insurer and Win. You can order this book on her website; perhaps you could request it from your local library. Her site is: health insurance help Laurie was kind enough to offer a chapter of her book, which will be attached to this post soon.

2. Listen or call in to the June 2 Boston show (see above link). She may be able to help you with your appeals too; see her site for contact information.

3. Look for her wisdom in a future Q & A column in the Cutting Edge forum.

And no, I have no business affiliation with Laurie. I am just trying to help you folks get the treatment you need. There will always be new treatments that are considered “experimental,” so we may need an army of Lauries….

Laurie, knock ‘em dead! I hope this post helps all involved.

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Fell on my ***winter 2003, Canceled fusion April 6 2004
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Old 05-21-2007, 08:38 AM
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Attached, please see an excerpt of Laurie's book. I hope this inspires and helps those of you needing guidance through the insurance maze!
Attached Files
File Type: pdf ToddExcerpt.pdf (121.5 KB, 136 views)
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Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
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Old 06-02-2007, 08:22 AM
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Sorry for the late notice, but should you be free now to listen to Laurie on the AM radio, or the web -- she's on for 2 hours!

The Internet:
http://mikerobertswebdesign.com/wcrn/listen.htm
Be patient with the connection...the recording will be archived for future access too.

Saturday, June 2, 11:00 a.m. till 1:00 p.m.
WCRN 830 (am station in Worcester, Mass.)
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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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Old 06-03-2007, 12:08 PM
ZorroSF ZorroSF is offline
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http://mikerobertswebdesign.com/wcrn/schedule.htm

Michael Savage...we're supposed to believe something on rant radio?



here's the archived MP3 of the Laurie Todd interview. The MP3 will only be up on that website for 1 week. next Sat it will be removed.

I've created a mirror site for everyone who misses this thread and can't grab it soon enough.


1st Hour of Interview
http://www.jumbodir.com/get/?id=8949...f-14771a3e1c51

2nd hour of interview
http://www.jumbodir.com/get/?id=d2bd...d-fa39b230e05a
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Old 08-27-2007, 06:13 PM
epiphaknee epiphaknee is offline
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For those living in the state of Washington:

Laurie Todd is going to speak at the Federal Way and Mercer Island branches of the King Library System on the below dates. This presentation is free. I also think she may be speaking at the Issaquah branch on September 25, 2007 (but check with the branch on this).

See Federal Way Regional Library, Wednesday, August 29, 7pm
Mercer Island Library, Wednesday, November 7, 7pm

Also see link at: http://www.kcls.org/events/author.cfm#todd


Federal Way:
Federal Way Regional
Library
34200 1st Way S., Federal Way, 98003

Mercer Island Library
4400 88th Ave. S.E., Mercer Island, 98040
206-236-3537
253-838-3668
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Old 09-05-2007, 08:40 PM
epiphaknee epiphaknee is offline
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Laurie Todd is speaking at the Issaquah, King County library on September 25th, 2007. It starts at 7:00 pm. Thereafter, she is speaking at the Mercer Island branch as discussed above. Again, these locations are all in western Washington.

Laurie is a great speaker and she has definitely "Been There" and "Done That". What a great resource. She also sells her books at these presentations.

She stated she is 23-0 in assisting others with their appeals. She can no longer afford to help others but I think her track record speaks for itself!!!

Very encouraging.
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Old 09-06-2007, 06:05 AM
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Thanks epiphaknee, for the update. If you go, give Laurie my best!
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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
  #8  
Old 09-25-2007, 05:07 PM
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The Insurance Intelligencer
9/24/07

UPCOMING ENGAGEMENTS IN THE SEATTLE AREA

This coming week ... Issaquah Library, September 25, 7:00 p.m.
Discover U Seminar, October 17, 6:30 p.m.

**** NEW PODCAST ON MY WEBSITE ****

Do you know a group or organization that needs to hear the I.W. story?

PPO Pitfalls

Or should I say “pratfalls”?

The majority of insured people these days belong to PPO-type organizations. When I ask them what “PPO” means, they say, “It means that I get to go wherever I want for medical treatment.”

These PPOs are often sold on the basis of choice. They are even named with this “enhanced choice” marketing in mind: First Choice, Best Choice, Acme Freedom Insurance.

PPO – what choice do you have?

Not so fast. This type of organization is not so different from any other type of insurance set-up. It involves a group of medical providers who are contracted with the insurer. In other words, these providers have a contractual relationship with the insurance company, which obligates them to accept whatever fee the insurer sets for their services.

Here’s where the choice comes in. In the HMO world, the Primary Care Physician is the gatekeeper—the person in charge of controlling access to services. If you had a persistent bladder infection, and wanted to see a urologist, you had to first sell your request to your Primary Care Physician.

Many years ago, I belonged to an HMO in California, and I encountered just such a situation. After nine months of suffering with a bladder infection, and begging and pleading to be referred to a urologist, I decided to change my tactics (I was already a budding Insurance Warrior). “OK,” I said to the immovable PCP, “How about sending me to a psychiatrist? This infection is driving me crazy.”

He sent me to the psychiatrist, who had no problem sending me to a urologist. Finally, I got the right medication, and the nine-month suffering was over.

In the PPO world, you are allowed to send yourself to a specialist, without going through the Primary Care Physician ... as long as they are within the group that is contracted with the insurer.

Is it as simple as that? Do you simply make an appointment? Not necessarily.

The Pre-Authorization Review

A near-universal feature of PPOs is the “pre-authorization requirement.” Before you go anywhere—in or out of the network—you may be required to request the treatment, and get your pre-authorization. At the HMO, you are required to visit your PCP, and debate with him in person. At least you are arguing with a doctor. With this pre-authorization process, your request drops into the same shadowy no-man’s-land where appeals go.

We recently had a request for out-of-network treatment denied. The next step was a “peer-to-peer” review. Sounds like they find a doctor who is knowledgeable about the treatment—a true peer of your expert—and he renders an opinion on whether your really need it, yes?

The treatment was a chemoembolization procedure, which is performed by a medical oncologist specializing in inoperable liver tumors. The insurance doctor who denied the request was a recently graduated family practice physician, with no experience in oncology. Sort of like the doctor working for the auto insurer, whose job it is to tell you that you didn’t get injured.

If they deny your request, you will have to write an appeal. Sounds like less choice to me, not more choice.

Going out of the network

You have an “out-of network benefit,” yes? This means that you can go to any specialist anywhere, right?

So not so. First, you will have to go through an even more draconian “pre-authorization review.” I guarantee you, if you request an expensive out-of-network treatment, it will be denied every time. Your insurer will state that they are not going to pay because the treatment which you have requested is “experimental,” “investigational,” or “not medically necessary.”

How you overcome these objections is another newsletter. Suffice it to say that the insurer isn’t going to make it easy for you.

Let’s say that, by some miracle, your insurer says, “Sure, we’ll pay for it. Go wherever you want for your treatment.”

Before you go anywhere, you had better count up your total net worth. Your out-of-network benefit is an illusion of choice, all smoke and mirrors. There are staggering financial disincentives, should you need to seek treatment from a doctor who is not contracted with the insurer:

• Higher deductible. Your out-of-network benefit could be subject to a separate deductible, or a deductible that is thousands of dollars higher than the one that applies within the network.
• Higher out-of-pocket. You could be required to pay out thousands more, before the insurer starts to pay.
• Separate cap. Your out-of-network benefit may actually have a cap on it, separate from your lifetime maximum. “Cap” means that that is all they will pay, ever.
• They only pay 50%-70% of charges that they deem “reasonable and customary.”

Let’s say that your cancer surgery plus hospitalization will cost $200,000 (a cheap date, in the world of cancer cures). First, you pay your special out-of-network deductible for tests and office visits relating to the surgery of $1,500. Then, you pay an assortment of co-pays prior to the surgery to the tune of $400.
Finally, when you get through the surgery, your insurer only pays 60%. Not 60% of the $200,000 which was billed, mind you, but 60% of what THE INSURER DEEMS TO BE REASONABLE AND CUSTOMARY, which could be 60% of anything. Just for the sake of argument, let’s say that they decide to pay 60% of $90,000, or $54,000.

Because your out-of-network surgeon is not contracted with the insurer, he is perfectly within his rights to balance-bill you for whatever the insurer doesn’t pay.

You are recovering from your surgery, and you start receiving bills which reach a total of $147,900. Of course, if they have a low cap on the out-of-network thing, you might be paying even more than that.

Some choice, eh?

If you have a PPO, and you need expensive treatment out-of-network, forget that you have any out-of-network benefit at all. Treat the insurer’s offer to pay as a denial, write a blockbuster appeal, and make them pay it all. By that I mean “90% of billed charges, with no patient responsibility.”

Good Insurance Warrior-ing,

Laurie Todd
__________________
"Harrison" - info (at) adrsupport.org
Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
Founder & moderator of ADRSupport - 2004
Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
Creator & producer, Why Am I Still Sick? - 2012
Donate www.arthropatient.org/about/donate
  #9  
Old 10-27-2007, 04:08 PM
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Ask the Insurance Warrior
10/21/97

The Insurance Warrior Speaks!
Listen to my podcast at www.theinsurancewarrior.com
********************

Q: What is an independent review? Am I entitled to one? Does my insurer have to abide by their decision?

A: The independent review holds several pitfalls for us. However, there are ways to turn this process to our advantage.

Let's say that you have requested a treatment (surgery/medication). Your insurer has denied your request, using one of the three all-purpose objections of health insurers: Experimental, Not Medically Necessary, or Out-of-Network.

Where the independent review comes in depends on the rules set forth by your insurer. You may get such a review after one denial, after two denials, or when all appeals have been exhausted.

Remember, each state has its own body of laws concerning insurance. If you are involved in any type of denial or dispute with your health insurer, it behooves you to find out what kind of protections exist for you under state law. Some states have a "Patients' Bill of Rights" that can be used to nudge your insurer into action. Why not call your Insurance Commissioner and find out?

Let's see how the independent review process plays out in real life, so that you can make sure that this "review" is not just a rubber stamp on the insurance company's denial.

What is an independent review?

It is supposed to be a review conducted by an "Independent Review Organization (IRO)." This IRO is accredited by your state, and is supposed to have no affiliation with your health insurer.

If your case is under "independent" review, you are entitled to know the name of the reviewer. Then, run like the wind to your computer, and Google him. If you discover that he works for your insurance company ... you suddenly have a very intimidating and embarrassing piece of information to use as leverage.

Am I entitled to an independent review?

Depends on your state's law, and the provisions of your insurance policy. Most states do call for an independent review, after all appeals have been exhausted. Be sure to call your state's Insurance Commissioner and find out.

Does the Insurer have to abide by the decision of the independent reviewer?

NOT NECESSARILY. What, you say? You are entitled to a review, and your insurer is entitled to ignore it? It depends on the insurance regulations in your state. We have had denial of care cases that went all the way to a third denial. Then, the independent review came to pass. The reviewer ruled that the insurer needed to pay for the treatment, which should be considered standard of care for this disease. Guess what? The insurer ignored the reviewer's opinion, and denied again.

If the independent reviewer decides that the insurer needs to pay, and state law requires the insurer to abide by the reviewer's decision, then they have to pay, right?

WRONG ... if you belong to a group plan. Individual policy, they would have to pay. In the case of a group plan, federal law trumps state law. The insurer denies. The reviewer tells them to pay. The state tells them that they have to act according to the reviewer's decision. If the insurer still doesn't want to pay, they simply kick the case up to ERISA, the federal agency that is concerned with pensions and benefits.

If you belong to a self-funded plan, by the way, neither your insurer, nor your employer, is subject to state insurance regulations. Because, under the self-funded set-up, the insurer becomes a “third-party administrator.” The insurer is not an insurer anymore, and they are not subject to state insurance regulations. And your employer -- who has ultimate say on whether your treatment gets funded – is not an insurance company either, nor are they subject to state insurance law. ERISA is your only recourse.

Have I told you lately to run, run like the wind from self-funded plans?

If you are suffering from cancer, just try appealing to the federal government. The ERISA appeal period is eighteen months -- at best. If your insurer starts talking about sending your case to ERISA, and you call them to explore your options, they will say, "Get a lawyer."

My advice? Do not look to any independent review process to save your life. Write a blockbuster appeal as outlined in my book, and take charge of the process yourself. Prove to the insurer with facts that ...

o Your case has been mismanaged in the most malpractice-worthy way.
o The treatment that they are proposing will lead to an expensive, malpractice-worthy outcome.
o The treatment that you are requesting is tried/proven/studied, and most likely to produce a good oucome.
o Precedent. Hello. They have already paid for this "experimental" treatment three dozen times.
o The treatment that YOU propose will cost less than the treatment that THEY propose.

Then, dig up a successful class action suit against your insurer, and find a clever way to make mention of it in your appeal. And be sure to "cc" the lead lawyer on that lawsuit ... this is a name that they will recognize.

Once you have written a bullet-proof appeal, and gotten it into the hands of the right decision-makers, you will not have to subject yourself to the nail-biting roller coaster of the "independent review."

Next time, we will talk about the so-called “peer review.” Are they really peers, whose side are they on, and how can you use them as “gold nuggets” in your appeal?

************************************************** *
I was at a party a few weeks ago, talking to an old friend. He said, “I keep trying to think of someone who might need your book, but I just don’t know anyone in that situation.”

“What?, “ I asked, “You don’t know anyone who has health insurance?”

THIS IS NOT JUST ABOUT RARE CANCERS.
THIS IS NOT JUST ABOUT CANCER.
THIS IS ABOUT ANY TREATMENT OR MEDICATION WHICH IS EXPENSIVE.

Hello. If you live long enough, you will eventually need something expensive from your health insurer.

Buy the book for all of your insured friends at my website: www.theinsurancewarrior.com
__________________
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Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
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
  #10  
Old 11-15-2007, 01:38 PM
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Here's another update from our friend Laurie. Patients and doctors in Arizona may want to check out this event!
________________________

Insurance Warrior Offers RX to make Insurers Pay

Cancer survivor Laurie Todd fought her health insurer’s denial of care and won; she now offers a battle-tested 10-step plan to help others fight back when insurance won’t pay.

The U.S. healthcare system is focused on controlling costs by denying care. This industry-wide posture causes everything from financial ruin to death. And yet the medical care that cost $1 million in 1970 would cost at least $16 million today.

Recent cancer survivor Laurie Todd has come to the rescue of patients nationwide. With her new book Fight Your Health Insurer and Win: Secrets of the Insurance Warrior, Todd shows ordinary people how to get insurers to pay their fair share.

Diagnosed in 2005 with appendix cancer, Todd was told by her doctors that post-operative treatment wasn’t necessary, and that her condition was manageable. Todd’s research suggested otherwise. The 57-year-old Washington native discovered a proven but expensive combination of surgery and chemotherapy, but was told by her oncologist, “There is no treatment for your disease. And, even if there were, they wouldn’t pay for it.

Ms. Todd worked tirelessly to appeal her insurer’s decision. First, she consulted with the world’s expert on appendix cancer. She then spent two months building her case—studying insurance law, gathering proof, and analyzing lawsuits against health insurers. Todd succeeded in getting her insurer to fully cover her lifesaving treatment, which totalled $345,000. Her share? Nine dollars.

Throughout 2006 Todd helped dozens of people, pro bono, to overturn denials of care—never losing a case. Many insurers, many conditions, all over the country. Seeking to spread the gospel further, Todd secured the backing of a major cancer research foundation to publish Fight Your Health Insurer and Win.

HEAR THE INSURANCE WARRIOR’S POWERFUL MESSAGE IN PERSON

Saturday, November 24 ● 10:00 a.m.

The Eccentric Gourmet
3434 W. Anthem Way #160
Anthem, AZ
ph. 623 551-4445
__________________
"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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