appeal update

[robby]

I had my appeals panel review Tuesday. The hearing went as well as it could have on my end. They told me several times that they were very impressed with my appeal and presentation. They even commented that I should come and work for them. I actually spoke well (many times I don't) and was very sharp and accurate with my information. I credit this forum and the Insurance Warrior for the majority of my appeal packet and background information. Your information is invaluable!

Anyway, after my presentation, they told me they could NOT change their policy on this type of surgery, they did not have the authority to do so. I don't understand how it can be called an appeal if they already knew they could not change the decision. I told them it was pretty much a waste of my time to come there (2.5 hours each way including the lawyer) if they could not reconsider their position on this type of surgery.

After again complimenting me on everything, they did, however, say they would expedite my appeal to an outside review doctor, something that seemed like they did not have to do. This outside reviewer has no connection with my insurance company and will be a neurosurgeon just like my doctor of choice. If this outside reviewer says I need this, then they WILL cover it. They say about 14 - 20 days before I will know.....more waiting.

My lawyer actually thought it went pretty well, as there was quite a bit of dialog between us and them, much more than we thought there would be. We thought we would get our 15 minutes and then they would kick us out. But we actually were in there with them for about 30 minutes and had some good conversions. If nothing else, I feel that panel is sooo much more educated and informed about ADR and something good should come out of this. The insurance company is reviewing its policy regarding ADR next month, and I would like to think that I helped inform them.

So I don't have the official denial of the appeal yet, but it should come in the mail any time now. But I still have hope of the outside review doctor. Anyone have good outcomes with that?

Robby

[Justin]

Robby,

Sorry to hear the news; been there done that.

After again complimenting me on everything, they did, however, say they would expedite my appeal to an outside review doctor, something that seemed like they did not have to do. This outside reviewer has no connection with my insurance company and will be a neurosurgeon just like my doctor of choice.

This does sound promising. However, this doctor is PAID to deny claims. At my appeal, the insurance company had an "expert" physician on their side and the "expert" physician representing me was Dr. Fenk-Mayer via telephone (a surgeon that works with Dr. Bertagnoli).

I was still denied. The insurance companies are like broken records.

Good luck and I hope your outcome is better.

Justin

Hi Robby,

It sounds like you gave it your best shot. I hope the final appeal goes your way.

Last week, I received my second denial with instructions on how to complete my third appeal. Get this - The instructions are to send it to the "Plan Adminstrator". Okay, the plan administrator is the V.P. of Human Resources! So I have come full circle and a non-medical person will make the final decision. This person by the way was suppose to be advocating for me the whole time. This is WRONG on so many levels!

On top of all this if I have ADR, they will not cover any revisions so...I see my doctor tomorrow.

Again, best of luck with insurance.

[sessler]

Hi Robby,
I am sorry to hear about your appeal. Who is your insurance? I am going on my Thrid appeal with Blue Cross/Blue Shield of Nebraska. I've bought Laurie's book and in the process of gathering information.

You probly don't know me because I haven't posted in a long time. My computer system was soooo old that all I was able to do was read all posts. Now I am back!

Anyone with samples of appeal letters or info on the Charite please let me know and if you have the same type of insurance as I do.

Thanks
Sue S
(I am also a Sue so we will do Sue S)

[robby]

Sessler

I have Anthem BC/BS. The majority of my appeal info came from Laura's Book and resources. Her information is top notch.

Robby

[CindyLou]

Sue (and Robby and .....), that is exactly how my appeal process hell went. The Plan Administrator just means your employer. (or so I was told by our healthcare provider) And mine also turned out to be V.P. of Human Resources making final decision with owner/President of company...non-medical folks. She (vp) even gave me the personal final interview appeal, and already had their decision made and told me "no" in person. (I also read Laurie Todd's book, had numerous phone conversations with her, emails, more phone conversations, and paid her to write my "outline" for appeal.) Let us never forget for one minute: it's all about the money, always! Robby, as Justin wished, I hope you fair better with your final appeal. Let's hope you can win final appeal and be the cogwheel that moves this mountain of denials the other way towards COVERAGE.

Good luck!

[robby]

Thank you CindyLou for your words of encouragement. I keep hoping for a postive outcome, but I am running out of options with this one.
I will let you know as soon as I receive word!

Robby