Pushing Back When Insurers Deny Coverage for Treatment

Sep 24, 2008

From the Wall Street Journal Online:

   

Battling a health insurer when it refuses to cover certain treatments can be aggravating and time-consuming. But if you choose to join the growing number of people who are appealing coverage denials, there are several strategies that can bolster your case.

More and more people are appealing insurers' denials of coverage, but that doesn't mean it's gotten any easier. Watch the story of on couple's struggle to get the treatment they wanted. WSJ's Anna Matthews reports. (Sept. 25)

Some health-coverage problems -- such as when your doctor enters a wrong code on a claim form -- can be resolved with a phone call. But other issues can be more difficult, because they center on complex medical questions like whether a certain cancer treatment is appropriate for you. Faced with such a situation, you may need to enlist help from your doctor, and even do some scientific research of your own. As a last resort, most states will consider appeals that have been denied by private insurers.

Insurance companies generally don't disclose how many appeals they receive. But state regulators keep data on the frequency of cases filed with them, and the trend is up -- 12% growth between 2004 and 2006, according to a survey by America's Health Insurance Plans, an industry group, which says such appeals represented less than one out of every 10,000 insured people. That's a small share of the total, though, since most appeals never get to the state bodies.

New York's regulator, the state Insurance Department, is one of the few agencies that also keeps track of how many people in its state file appeals with health insurers. In 2007, the number was 33,355, up 18% since 2004.

Self Protection

Having a game plan when fighting a health insurer's denial of coverage can better your odds of a successful appeal.

  • First, find out what led to the insurer's decision, and keep a careful paper trail.
  • Be prepared to prove that your treatment qualifies for coverage under your plan.
  • Even if your insurer rejects your appeal, most states will consider appeals as a last resort.

Why the increase in appeals? Patient advocates and state officials say the weak economy and ever-rising health-care costs put pressure on insurers to squeeze expenses by denying claims, and leave consumers watching their spending more closely. But the insurance-industry group says the growth is likely fueled by insurers' efforts to educate consumers about their rights. Several companies say they are working to make the process easier, but many aspects are mandated by state regulators.

In any case, appealing an insurer's decision is often complex and tricky, and the deck can seem stacked against you. It is often hard for consumers to know what is covered and what isn't in an insurance plan. Indeed, insurers have been winning a majority of the cases reviewed by state regulators in recent years, with victories for insurers at 59% in 2006.

Here are some ways you may be able to better your odds.

Getting Started

First, figure out what led to the denial of coverage and learn your insurer's procedure for appeals. When you call your health plan to get the information, take notes and get names. If the problem can't be readily resolved, you should ask the insurer for some key documents to reconstruct what led to the rejection.

An Appealing Option

If you are considering appealing a decision by your health plan, here are some online resources that can help.

Tips and tutorials on how to file an appeal:

Where to call for advice

There are a growing number of health consumer advocacy operations that will work with people who want to file appeals. Before you hire anyone, ask about fees and success rates.

Nonprofits:

  • The Patient Advocate Foundation is a nonprofit that works on appeals
  • Families USA offers links to state-based advocacy organizations and state-government health advocates. Not all of these groups work on appeals.

Some of these companies work mainly for employers who hire them to help employees, so check if your employer has hired one, or ask if the advocate can be hired by individuals:

You will need the denial letter. You should also get a copy of your plan's full benefits language, sometimes called the "Evidence of Coverage," as well as the detailed guidelines that explain what the company considers medically necessary. Some companies, such as Cigna Inc. and Aetna Inc., post their medical policies online.

Sometimes the appeal is straightforward. Murielle Curcio, 51 years old, of San Jose, Calif., was told by Blue Shield of California last October that it wouldn't pay for a genetic test to gauge her risk of breast cancer. The letter said the test hadn't been preauthorized by the company or performed by her primary-care physician. With more than $3,000 at stake, Ms. Curcio enlisted the help of Health Advocate Inc., a firm that works under contract with her employer.

Ms. Curcio filed an appeal in January. She says she got a letter from the testing lab confirming that her physician had ordered the test and that his office had been told by the insurer that it would be covered. In her appeal, Ms. Curcio also cited the insurer's policies to argue that such tests were covered by her plan, and that she was a medically appropriate candidate. A few weeks later, Blue Shield paid for the test.

A Blue Shield of California official said he couldn't comment specifically on Ms. Curcio's case because the insurer hadn't received a release form from her. But the official said appeals often stem from a lack of complete information, and "the most common reason for overturning a decision is, we get information we didn't get at the outset."

Building a Case

After you gather the facts, set a strategy. Your appeal may hinge on proving that your treatment qualifies for coverage under your plan's benefits and rules. Tom Bridenstine, managed-care ombudsman for the state of Virginia, says he once worked with a consumer whose insurer refused to pay for bariatric surgery because such obesity treatments weren't allowed benefits. Mr. Bridenstine says he helped win a reversal by showing that the woman's weight issue was actually a symptom of a rare disease.

[When Insurers Deny Coverage] Getty Images

Many appeals focus on demonstrating that a treatment is scientifically proven and medically necessary. Your doctor should be able to write a detailed letter on your behalf. You also may be able to bolster your case by researching the scientific evidence online on sites like pubmed.gov, sponsored by the National Library of Medicine.

David Foglesong, a history professor from Montgomery Township, N.J., began searching medical databases soon after Horizon Blue Cross Blue Shield of New Jersey declined to pay for a targeted chemotherapy treatment for his wife, RoseMary. During one library visit, he found a new study that showed the treatment had helped patients with conditions similar to his wife's disease, advanced sarcoma that had spread to her liver.

The couple, advised by Patient Advocate Foundation, a nonprofit group, solicited new letters from Ms. Foglesong's doctors, and her primary oncologist argued on her behalf in a conference call with the insurance company's reviewers in June. The company reversed its earlier decision, and Ms. Foglesong, 49, got the treatment in July.

Horizon officials say the procedure was initially denied because it was deemed experimental and not the standard for Ms. Foglesong's condition. The company said a review committee reversed that decision because of the "whole totality of her case," including the medical literature.

Last Resort

Even if your insurer rejects your appeal, you still have other options. If your employer has a self-funded health plan, which might be administered by a private insurer but is backed by the employer, your next step is often to sue in federal court, a tough and expensive proposition.

If your insurer has denied your appeal, here are other resources to try.

  • If you have an individual policy, or your employer is fully insured, you can probably appeal to your state's outside review process. The industry trade group America's Health Insurance Plans includes shortcuts to many state agencies.
  • If you have Medicare, you can't use the state appeals process, but the federal program has its own review procedure: see guide for instructions.
  • If you are in an employer plan that is self-insured (meaning the company backs the plan itself), you also generally can't use the state review processes. The Department of Labor's website has information on the appeals process for such plans.

But if your coverage is with an insurance company, either through your employer or an individual policy, you can opt for your state's appeals process. Check with the agency, because the 44 states that offer independent reviews won't handle all kinds of issues, and each has its own rules.

Sharon Hines, 52, of Middletown, Conn., appealed to the state after her insurer refused to pay for Avastin, an expensive biotech drug that has drawn debate over what uses are justified. Ms. Hines, an oncology nurse practitioner, says she and her husband, a truck driver, couldn't afford the roughly $100,000 a year cost of the treatment.

Ms. Hines said her insurer, ConnectiCare Inc., a subsidiary of Health Insurance Plan of Greater New York, had raised various objections to Avastin, including that there wasn't evidence the treatment would work for someone, like her, who had previously taken Tarceva, another cancer drug. In August, the state's reviewer ruled that Avastin was medically necessary because Ms. Hines would be getting it with first-line chemotherapy, its approved use. "It was such a sense of relief," she says.

In a statement, a ConnectiCare official said the independent oncologist who reviewed Ms. Hines's appeal for the company "did not agree with the use of Avastin" and the insurer followed his recommendation. When the insurer got the state review's decision "we immediately covered the drug for her....We wish her well with her courageous battle."

Medicare Appeals

For Medicare beneficiaries, there is a separate, federal appeals-review process. That is what Ellen and Paul Hoppe used after Health Net of California, the Health Net Inc. unit that provided Mr. Hoppe's Medicare Advantage plan, declined to pay for proton-beam radiation for his prostate cancer. The denial document said there was no evidence that Mr. Hoppe, 67, would get any added advantage from proton-beam therapy, which is significantly more expensive than conventional X-ray radiation.

Need more research to bolster your appeal?

For evidence about the medical treatment you want: PubMed is a service of the U.S. National Library of Medicine that includes biomedical articles dating back to the 1950s.

Some health plans, like Aetna , Wellpoint and Cigna, post their medical policies online. Even if you're not covered by them, you may want to compare their policies to those of your plan.

But the Hoppes, phone-company retirees in California, were convinced that proton-beam therapy carried a lower risk of side effects such as incontinence. They got backing from Mr. Hoppe's doctor at Loma Linda University Medical Center, who wrote a six-page letter, including two pages of research citations. In June, Medicare's appeals contractor sided with the Hoppes, saying the proton-beam therapy qualified for the federal standard of "reasonable and necessary" treatment.

Health Net said in a statement that it couldn't comment on Mr. Hoppe's case because it hadn't received a release from him. But it said, "Any single portrayal of a less-than-satisfactory customer service experience does not represent the overall experience of our customers." A Health Net spokesman added that medical coverage decisions aren't affected by the cost of treatment.

Navigating the health-care maze is tough, and we are increasingly asked to make our own choices. In the new biweekly column Healthy Consumer, Anna Wilde Mathews explores costs and values, and how to be a smart health-care consumer.

Write to Anna Wilde Mathews at [email protected]

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What every DSer should have: The Poo Log...

Sep 19, 2008

I found this at Spencer's Gifts - and HAD to get it for Steph for her "last meal" party before her surgery we had last Tuesday.

The Poo Log Book at Amazon

In the Amazon link you can see the log pages in detail - it's hysterical, with checkboxes to detail the consitency, frequency, texture, explosiveness, etc, of your POO. 

With all potential DSers concerned about the stinky stuff that comes out of our butt, this log could put to rest once and for all - just how bad IS a DSer's poo post surgery?

Edit: I just noticed you can get 27 used & new available from $5.37 - so who is brave enough to buy a used poo log??!! 
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I sent flowers to the head of HR!

Sep 18, 2008



I felt so guilty about constantly asking how goes the new health insurance negotiations, etc, because I know she must have big wigs demanding she keep the cost of insurance down on the other side.

So I sent her flowers, she should get them today!

The note I included:

"Thank you so much for listening and putting up with my feverish campaign to the company to get the health benefits I need. People like you can literally mean the difference of life and death, you are appreciated! ~ Larissa H"

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Saving on vitamins and supplements!

Sep 17, 2008

Thanks to many fine DSers who have been passing around this info, I am posting here as a reminder to myself as well to be thrifty post surgery!

1) Many people purchase vitamins and supplements via www.vitacost.com because it is so reasonably priced AND has a FLAT shipping fee of only $5.99 no matter what you order. Great, right? WELL THAT'S NOT ALL!

2) You can create an account at www.ebates.com and click on THEIR link to vitacost.com to earn rebates on all purchases up to 5% - receive a check in the mail thanking you for buying your health supplements through them. So far - cheap prices + flat shipping + 5% rebate. Isn't that awesome...??? BUT WAIT (best Ronco voice) THAT IS STILL NOT ALL!

3) You can search for coupon codes that are good at vitacost.com via www.retailmenot.com, www.bigcrumbs.com, www.cashbaq.com and others - even simply google search - and you can use these coupons to save extra $$ on top of your rebates (as long as you use your ebates.com account to access vitacost.com).

Now, let me end my advice with saying vitacost.com is an excellent place to get good deals, but not an excellent place to get GOOD VITAMIN AND SUPPLEMENT INFORMATION for WLS patients specifically. That would be www.vitalady.com, which is run by an OH member and her husband who have taken the time to educate themselves and pass their wisdom on to the rest of us. When in doubt, check her site or contact VitaLady. And certainly, if cost is not a factor (she can be very reasonable, too, and offers many inexpensive trial samples), I encourage you to support her site and purchase through them if you can.
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More on the battle to get HR to include WLS in new health plans

Sep 09, 2008

Ok, see my blog for my history with working with HR. Sometimes I'm confident it will work, other times I feel hopeless...!!!

This is the latest in some communication with HR regarding upcoming insurance changes:

HR director to company employees:

As you know, we are in the process of combining our benefits offerings. 

....

We are working on our medical renewal and have narrowed it down to Anthem Blue Cross and UnitedHealthcare.  We plan to offer one carrier (either Anthem or United) with two choices.  The choices will be a traditional PPO (Preferred Provider Organization) and a (CDHP) Consumer Driven High Deductible Plan.

....

More information will be shared over the next weeks and your feedback is welcomed. 


Me to HR Director:

I’m very pleased to hear this as both these companies were my top choices, too. Dare I ask if coverage of the medical treatment of obesity is still on the table…?


HR director to Me:

Thanks for the feedback.  Medical treatment of obesity is on the table to be covered differently than it currently is (I think you’re asking about the surgical treatment options)   - and we’ll see.  Unfortunately cost will come into play at some point.

You know you’ll hear more from me…


WELL...that scared the bejeebus out of me, so I replied:


Me to HR Director:

I bet that wouldn’t be an issue if an employee had cancer from smoking. :(

HR Director to ME:

Actually we are looking at different premium rates if someone commits to not smoking – trying to make sure we can get it set up in HRB . ..

Me to HR Director:

I don’t smoke! lol

And I will be HAPPY to pay a higher premium for my weight (although – you wouldn’t make someone with breast cancer pay a higher premium – and I believe both are genetic and not lifestyle issues) if it meant I would get coverage.

HR Director to Me:

I hear what you’re saying and respect your desire ..one part I’m struggling with is that this is an additional cost to everyone on the plan – not just one person…

I’m glad we’re able to talk about it openly…


Me to HR Director:

I can’t tell you how comforting it is that an HR department would keep an open dialog with an employee.  

On that note – I’m going to just leave you now with a few more points: 

1.   >>>Studies show not only is bariatric surgery a proven medical procedure with an outstanding track record, but it is cost effective in as little as two to four years.

“The analysis covered six months of presurgical evaluation and care, the surgery itself and, on average, about 18 months of postsurgical care, including costs incurred from surgical complications. Some patients' postsurgical claims were tracked for up to five years. Costs included payments for prescription drugs, physician visits and hospital services. Claims were monitored for obese patients who didn't have surgery over the same period.

The study showed that insurers fully recovered the costs of laparoscopic surgery after 25 months. Laparoscopic surgery is a less-invasive version of gastric bypass with an average cost of $17,000. Between 2003 and 2005, the break-even point was reached in 49 months for traditional bariatric surgery, which carries an average cost of $26,000.”

Source:

The Wall Street Journal

2. >>> Having said that, many experts wonder why surgery for one disease has to prove cost effectiveness when others don’t?

“Dr. Finkelstein said that over time he has come to believe that the ‘return-on-investment’ analysis of weight-loss surgery is ‘misguided.’ This economic metric isn't used to evaluate the cost-effectiveness of treatments for cancer or heart disease.”

3.   >>>In the end, whether it is effective at stopping the deadly disease or great reducing its effects on the health of the patient should be the only true cost measured. I am not the only obese person in this company, and it’s not just my life worth being measured here. This company is going to make its feelings shown on how much it values the total health of all of its employees one way or another.

4.   >>>One would wonder what the results would be if you took a poll of employees: “We have an employee here with cancer that can be cured but it would mean our rates would go up $25 a year per employee – would you be ok with that…?”

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Celebrate Banned Books Week!!

Sep 07, 2008

http://entertainmentweakly.com/bannedbooks.jpg
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Great site for grass roots health care insurance action..!

Aug 25, 2008

I support Health Care for America Now
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Passing info along...

Aug 23, 2008



Walter Lindstrom
Chula Vista, CA
Member Since: 01/22/99


Hi folks....
I just logged on to the site for the first time in several weeks and found messages waiting for me that I didn't know about.  I apologize if people thought I was on daily and may have thought I was ignoring them.  Kelley and I  wanted everyone to know that if anyone needs to reach us for insurance related questions, appeals, representation, etc., call our office at 619-656-5251 (ask for Kelley Lindstrom) or email us -  [email protected] and [email protected] or visit our site, www.obesitylaw.com .  I try to log on here occasionally but direct contact is REALLY the best and quickest way to get a hold of us....
Thanks and hope all of you are well.

Walter Lindstrom
Obesity Law & Advocacy Center
www.obesitylaw.com
RNY Gastric Bypass 1994
LAP-BAND Revision 2003
Starting BMI = 59+
Current BMI = 30
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Extreme low cost plastic surgery in Texas?!

Aug 18, 2008

University of Texas SouthWestern Medical Center has an internship program for doctors in training that will do plastic surgery at a very low cost.

One OH member got a full lower body lift for only $3600!

Call for information:  214-648-9617
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How to prepare for WLS surgery..

Aug 11, 2008

This is a list of suggestions I've compiled.


3-6 months before:

Go ahead and get full WLS labs done.

Not to be construed as medical advice, this list is a WLS mainstay:

*80053 - comprehensive metabolic profile (sodium, potassium, chloride, glucose,BUN, creatinine, calcium, total protein, albumin, total bilirubin, alkaline phosphatase, aspartate aminotransferase) (10231)
* 84134 - pre-albumin
* 7600 - lipid profile (cholesterol, HDL, LDL, triglycerides, chol/HDL ratio)
* 10256 - (hep panel, includes ALT (SPGT) & GGT)
* 593 - LDH
* 84100 - phosphorous – inorganic (718)
* 83735 - magnesium
* 84550 - uric acid (905)
* 7444 - thyroid panel (T3U, T4, FTI, TSH) (84437; 84443; 84479; 84480)
* 85025 - hemogram with platelets (1759)
* 7573 - iron, TIBC, % sat
* 83550 - ferritin (457)
* 84630 - zinc (945)
* 84446 - vitamin A (921)
* 82306 – D (25-hydroxy) (680)
* 84052 - vitamin B-1 (thiamin) (4052)
* 84207 – vitamin B-6 (Pyridoxine)
* 7065 - B-12 & folate (82607; 82746)
* 83970 - serum intact PTH
* 31789 - homocysteine, cardio
* 83921 - MMA
* 367 - cortisol
* 84255 - selenium
* 83937 - osteocalcin
* 84597 - Vitamin K
* 82525 - Copper
* 84590 - Vitamin E

For diabetics: *496 - HEMOGLOBIN A1C

DIAGNOSIS CODES:

269.2 hypovitaminosis

244.9 hypothryoidism

268 vitamin D deficiency

250.0 diabetes

401.9 hypertension

276.9 electrolyte and fluid disorders

579.8 calcium malabsorption

579.8 intestinal malabsorption

272.0 hypercholesterolemia

275.40 calcium deficiency

266.2 cyanocobalamin deficiency

280.9 iron-deficiency anemia

269.3 zinc deficiency

281.0 pernicious anemia

281.2 folate deficiency anemia

281.1 other B12 deficiency anemia

285.9 anemia, unspecified

*579.3 surgical malabsorption*

Start taking multi-vitamins, and take extra according to what you are deficient in your lab results. Focus on Vitamin D, C, Calcium and Iron

Start some kind of excersize program, walking, swimming, biking, or just dancing in your underwear in your living room. Just get moving.


1-2 months before:

Start a low-carb diet, go through carb detox now and not while you are also trying to recover from surgery.

Load up on protien at every meal and snack if you can.

Do "foot wiggles" excersizes to help guard against blood clots. Wiggle up down, left right, as often as you can.

Do breathing excersizes to build strong lungs.

Try some stomach crunches and other strength building excersizes added to the program you are already doing.

Arrange for extra helping hands your first two weeks of recovery.

1 week before:


Take pictures, especially if you have been very camera shy up until now. Front, back, sideways and a face closeup. You might consider also takeing measurements of body parts for comparison down the line.

Stock up on liquids and protient drinks for the days after.

In addition to other breathing excersizes, blow up ten tiny balloons a day.

If you don't have a lazy boy recliner, consider borrowing one or renting a lift chair.
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