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What to Do When Your Insurer Won’t Pay

by Laurie Todd

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Diagnosed in 2005 with late-stage appendix cancer, I fought my health insurer?s denial of care and won. Here are some things you can do to reverse insurance denials.

Beware Insurance Words
Let's demystify the “Big Three,” and use them to our advantage:

1. Experimental/Investigational: Insurers sometimes deny treatments that are FDA-approved and pay for treatments that are not FDA-approved. They may pay for a treatment one week and deny it as “experimental” the next week. If you can prove that your treatment is not experimental and that they have paid for it before, they will most likely pay.

2. Not Medically Necessary: Look for this phrase in your insurer?s definition of medical necessity “as determined by the medical director of the insurance company.” Medical necessity is a legal term designed to place decision-making power over your treatment in the hands of the medical director of the insurance company. Prove that your treatment of choice is necessary, justified, and warranted in your case. Prove it with facts, and they will likely pay.

3. Out-of-Network: I had no out-of-network benefit. The surgeon that I needed was out-of-network. Out-of-network means out of luck, right? If you can prove that there is no physician in the network qualified to provide curative treatment for your disease, they will likely pay.

Put down the phone, pick up your pen, and follow these ten steps to a winning appeal.

Laurie Todd

Laurie Todd

Writing Your Appeal
Your surgery is scheduled for next week, and you receive a letter from your insurance company denying coverage. What will you do? Most people call the insurance company. Instead, put down the phone, pick up your pen, and follow these ten steps to a winning appeal:

1. Push the insurer to deny your treatment in writing. You may hear, “We never received your appeal, the case manager is on vacation, we don't decide until the day before the surgery.” Delaying is a tactic. Don't let it happen.

2. Write a full-fledged document. Include a title page, cover letter, table of contents, bullet list of facts, attachments, and conclusion.

3. Do your research. Become an expert on your insurer, your disease, your doctors, and your treatment. You must be able to argue for your treatment like a champion debater.

4. Address your appeal to the right decision-maker. And send copies to other important people who will check up on them. Good choices would be medical directors, insurance company executives, and lawyers who have sued them successfully.

5. Purge all emotion from your appeal. The minute you give in to feelings – especially anger or sarcasm – you could lose your case.

6. Tell your medical story, but don't tell all. Focus on the things that the insurance doctors did wrong. Don't accuse; just be factual.

7. Disqualify all unqualified insurance doctors. What if there are no experts in the network and the insurer insists that you stay in-network? Interview the in-network doctor, ask qualifying questions, study his resume. Then, put all this in your appeal.

8. Supply precedent. Build a list of cases where the insurance company has paid for this treatment before. Join an online group for your disease, and call out for precedent.

9. Conclude with the cost comparison. This is all about money. Prove that what you are proposing will cost less than what they are proposing.

10. Push the appeal along. They will be very polite: “We lost the fax, wait for our call, wait for our letter.” This could continue indefinitely – until you take charge.

Ten steps is the gold standard. If you do three of the steps – and do them well – you will probably win your appeal. Do not rely on doctors to appeal for you. The doctor who is contracted with the insurance company cannot mount the most powerful appeal. The doctor who is not contracted with the insurer has no influence with them. You, the insured, are the only one who has any traction with your insurance company.

You, or your friend or family member, will need to step up to the plate and write your appeal. We, as cancer survivors, should embrace these battles and win them together. By doing so, we reclaim our power and find our own voice.

♦ ♦ ♦ ♦ ♦

Laurie Todd is a speaker and author of the book Fight Your Health Insurer and Win: Secrets of the Insurance Warrior.

This article was published in Coping® with Cancer magazine, July/August 2008.