What if My Insurance Won't Pay?
Insurance coverage for medical treatments and prescription drugs is a critical issue for carcinoid cancer/neuroendocrine tumor patients. The Carcinoid Cancer Foundation is delighted to partner with Laurie Todd, “The Insurance Warrior,” to bring you cutting-edge information about how to fight your insurance company if your claim is denied. Please visit this page often as we will frequently add new information.
Who is The Insurance Warrior?
 Laurie Todd is an author, teacher, and insurance strategist. With a secondary teaching certificate and an M.A. in French Literature, Laurie was perfectly poised to unmask insurance company words, and teach others to do the same.
In 2005, Laurie was diagnosed with late-stage appendix cancer. She was told by her oncologist, “There is no treatment for your disease. And, even if there were, they wouldn't pay for it.”
Laurie worked tirelessly to reverse her insurer’s denial. She spent two months building her case—studying insurance law, gathering proof and precedent, reading medical journal articles, interviewing the experts.
Ms. Todd succeeded in persuading her insurer to fully cover her lifesaving treatment with Dr. Paul Sugarbaker, which totaled $345,000. Her share? Nine dollars.
From 2006 through 2009, Laurie has helped dozens of people to overturn denials of care. Many insurers, many conditions/diseases, all over the United States. She has never lost a case.
Seeking to help more patients and medical providers, Laurie secured the backing of a major cancer research foundation, and published her book, Fight Your Health Insurer and Win. She has also written articles that have appeared in Coping with Cancer magazine (July/August 2008) and in the YES (Y90 Microspheres Education and Support) newsletter.
Visit Laurie’s website, www.theinsurancewarrior.com, and learn more about this remarkable woman and all she has achieved for patients.
Your Battle Plan: What Is An Appeal?
The following information are excerpts from Laurie Todd’s CD, The Sample Appeal: More Insurance Warrior Wisdom, about how to write winning insurance appeals. In this CD, she has documented and explained every part of her appeal strategy — from the day your insurer denies, to the day they approve the treatment. Her book explains the basic principles of dealing with insurance bureaucracies, and lays the groundwork for writing an appeal.
With every appeal that Laurie has fought and won, she has learned something new, and sharpened her strategies. In this CD, she shares everything that she has learned in the course of writing and winning forty-four appeals.
Read earlier excerpts from Laurie Todd's CD:
- Current -- Excerpt 20 "Rational for Denial: Mop up all Resistance"
Next --
Excerpt 20:
Rational for Denial:
Mop up all Resistance
Let's go back to the most critical document in your strategy game with the
insurance company—the denial letter.
You have already dealt with their "stated reason for denial"—by studying and demolishing their definition of "experimental" or "not medically necessary" in your appeal.
Now, let's finish them off by going after their "Rationale for Denial."
"Rationale" means "underlying reason." In an insurance context, underlying
reasons = scientific proof.
Insurance companies do not always mention their rationale in the denial letter. If they do include it, I am delighted. Why? Because insurers always pull their proof from their own medical policy statements. And, most medical policy statements are poorly written, out of date, and off message—with feeble, inappropriate proof that is easily disproved in an appeal.
Don't stop at rebutting your insurer's definitions. Take your battle right to the
heart of their argument—the rationale.
Their rationale always comes straight from the Medical Policy Statement, which
you already have in your possession.
You have already picked apart the verbiage in the med policy, to see how to
turn it to your advantage. Now, you are going to boldly go where no insured
person has gone before—into the "References."
"References" is the list of studies, professional organizations, government
entities, or other sources which are listed at the end of the Medical Policy
Statement. You will have to dig into them a bit, and demolish them in your
appeal.
You will be amazed at how easy it is to discredit insurance company proof, and
how powerful your discrediting will be, when you include it in your appeal.
In the Sample Appeal, Acme Insurance gives two underlying reasons for denial.
I dedicate one section to each reason.
ACME OFFERS SPURIOUS PROOF:
HAYES DECLARES THEIR ASSESSMENT OUT OF DATE
______________________________________________________________________________
In the First-Level Appeal Decision, Acme's entire clinical argument against this
treatment rests on two documents:
1. Hayes Technology Assessment Report dated June 10, 2006
2. NCCN Guidelines
I will prove with facts that neither one of these sources has any validity whatsoever.
Hayes declares their Assessment to be out of date
Physician Dr. Savady requested the Hayes Technology Assessment report for
"Intraperitoneal Hyperthermic Chemotherapy for Abdominopelvic Cancers" dated
June 10, 2006. Hayes would not sell him a copy of the report, and the letter
explains why (Att. 3):
"The Hayes Report mentioned above, Intraperitoneal Hyperthermic Chemotherapy for
Abdominopelvic Cancers, published June 10, 2006 is not available for purchase
because it was last published more than 2 years ago and some material may be outdated."
How outdated is the Hayes Assessment?
Very. Let's consider a few examples of how out of date this assessment is:
- The ThermoChem-HT machine which is listed as "approval pending" was approved
by the FDA in 1999.
- The "Studies evaluating the safety and efficacy of intraperitoneal chemotherapy"
date from 1980, 1988, 1994, 1997, 1998, 1999, 2000, 2003, 2004 and 2005.There
is exactly one study from 2006. Does the addition of one paper constitute an"update"?
Is a paper from twenty-eight years ago really useful in evaluating this treatment?
- Hayes found three Medical Policy Statements from insurers that do not
approve of this treatment for appendix cancer (Aetna, AmeriHealth, and Regence BC/BS).
I found five Medical Policy Statements from insurers that do approve of this
treatment for appendix cancer:
United Healthcare
HealthNet
Empire BlueCross BlueShield
Cigna
Anthem BlueCross BlueShield
NCCN OFFERS NO OPINION ON THIS TREATMENT
NCCN MEMBER INSTITUTIONS EMBRACE IT
______________________________________________________________________________
NCCN Guideline do not mention this treatment
Dr. Griswold, the unqualified reviewer from the Level I Appeal Decision, says:
"I have consulted with a physician who is board-certified in hematology/oncology.
He consulted the National Comprehensive Cancer Center Guidelines and related
to me that hyperthermic intraperitoneal chemotherapy is experimental in your
clinical situation."
If this medical oncologist "related" to Dr. Griswold that hyperthermic
intraperitoneal chemotherapy is experimental, he didn't find it in the NCCN
Guidelines. Why? Because the NCCN Guideline for colon cancer makes no
mention of this treatment.
Five NCCN member institutions endorse cytoreductive surgery and HIPEC
Absent any NCCN statement about cytoreductive surgery and HIPEC, how then can
we determine what is their position on this treatment? By their actions.
The National Comprehensive Cancer Network is comprised of twenty-one member
institutions. Surgical oncologists at five of these NCCN institutions signed the
Consensus Statement endorsing cytoreductive surgery and heated intraperitoneal
chemotherapy for abdominal malignancies including ovarian cancer.
University of Washington, Fred Hutchinson Cancer Center
MD Anderson Cancer Center
H. Lee Moffitt Cancer Center
Roswell Park Cancer Institute
Johns Hopkins, Sidney Kimmel Comprehensive Cancer Center
(Esquivel J, et al. Cytoreduction and hyperthermic intraperitoneal chemotherapy
in the management of surface malignancies: a consensus statement. Ann of Surg
Oncol 2006;14(1): 128-33.)
NCCN managed to find medical oncologists at these five institutions who didn't
mention this treatment, one way or the other. I have found surgical oncologists at
the same five institutions who have spoken out publicly in favor of it.
Two NCCN member institutions are high-volume HIPEC centers
MD Anderson is one of the NCCN member institutions. Dr. Paul Mansfield has
performed hundreds of cytoreductive surgeries with HIPEC there, and published
extensively about it. Roswell Park is also an NCCN member institution, and Dr.
John Kane has performed at least fifty cytoreductive surgeries with HIPEC. For
some reason, NCCN didn't seek an opinion from either of these two experts. I'm
sure that they would be surprised to discover that their institutions are invoked to
deny the very treatment upon which they have based their careers.
On balance, Kaiser's effort to paint NCCN as opposed to HIPEC and cytoreductive
surgery is feeble at best, deliberately deceptive at worst.
The reviewer in this case has pulled two items out of the medical policy statement,
and used them to justify Acme's denial.
We discussed medical policy statements in Chapter 2. As soon as you receive your
denial, you want to see if your insurer has a medical policy statement (also known
as "treatment guidelines") that covers your treatment.
I have supplied a sample medical policy statement as a separate PDF file (see "Med
Policy Example.pdf). References are like footnotes to the med policy—a list of
articles and other documents that supposedly support their assertions.
This med policy from Priority Health lists five references. Some med policies—in an
attempt to overwhelm you—list twenty-five or fifty or eighty references. Don't be
alarmed. Acme will mention two or three in their denial, and you will disprove and
discredit them.
What if Acme Insurance doesn't mention their rationale in the denial? If it were
me—I would pick out the weakest two or three references, and discredit them just
for fun.
Show them that you aren't afraid to dig into this material.
The bean counters at Acme Insurance who review your appeal is not going to
bother to delve into the med policy or its references. Get up earlier in the morning
than they do, find the weak spots in their medical policy, and point them out in
your appeal.
They will know for sure that you are smarter—and more motivated—than they are.
They will throw their hands up and finally say, "This is way too much trouble.
Let's just pay."
Hayes Technology Assessment is out of date
I chose the Hayes Technology Assessment, because it is a perfect example of the
type of mysterious, official-sounding sources that insurance companies like to use.
Insurers often cite this "Hayes Medical Technology Directory." Check the med
policy for your treatment; you will likely find Hayes quoted there. 99.9% of
patients assume that this is a very official organization, that they disapprove of the
requested treatment, and there no way to refute it.
By the time that I noticed how often Hayes was rearing its ugly head, I was a
veteran of forty-four winning appeals. I finally asked, "Who are these Hayes people,
anyhow—and what do they really say in this "assessment?"
Whenever some supposedly official group is mentioned by the insurance company,
get on the Internet and find out who they are.
I looked at the Hayes website. They are a private company; they exist for the
benefit of insurance companies. They publish a huge directory covering hundreds
of medical treatments. For each treatment, they do a basic literature search, then
list what three different insurance companies medical policy statements have to
say about the treatment.
Sounds incestuous doesn't it? Medical policy statements being used by insurance
companies to support other medical policy statements of other insurance
companies.
Do you suppose that Hayes is motivated to find literature that SUPPORTS
promising and expensive new treatments? Not likely. They serve as proof and
back-up for insurance companies. Insurance companies are their customers,
insurance companies are the only ones who have copies of this directory.
I searched high and low for a copy of this Hayes assessment. I searched the public
library, I searched the Web, I searched medical libraries. I was beginning to think
that insurance companies were deliberately keeping this Hayes Directory to
themselves, to make it harder for folks like you and me to debunk it.
Finally, I asked a doctor friend to order a copy of this Hayes assessment. He
received a response on official Hayes stationery, saying, "We don't sell that
assessment anymore. It was last reviewed in 2006, and parts of it may be out of
date." Major gold nugget for the appeal, and for all future appeals for this
treatment.
I finally got ahold of the Hayes assessment for cytoreductive surgery and HIPEC.
Guess what? It consisted of fifty-five pages of fluff, bluff, and bluster. Articles
from 1980, studies that didn't prove their point.
They stated that the FDA approval for the HIPEC pump was "pending." The pump
was approved by FDA in 1999. Ridiculous.
Hayes found three med policies that were against HIPEC. I found five med policies
that were in favor of it.
See how it's done? Like shooting fish in a barrel.
NCCN Guidelines
NCCN Guidelines are another popular rationale for insurance companies. After
running across NCCN many times, I asked, "Who are these people? Are they really
against this treatment?"
Would you be surprised to find out that they are nobody official—and they are not
against this treatment? Once again, it's a bluff.
NCCN stands for "National Comprehensive Cancer Network." Sounds official,
doesn't it? I believe that this acronym is supposed to make us think of the NIH
(National Institutes of Health), or the NCI (National Cancer Institute), which are
official government entities.
On their website, NCCN calls themselves "an authoritative source." When a group
calls ITSELF authoritative, I begin to wonder.
The National Comprehensive Cancer Network is an affiliation of twenty-one cancer
treatment centers. Certain doctors from these medical centers get together, and
formulate "practice guidelines" for cancer treatment.
We know how much insurance companies love "guidelines." They use them to
support denials of treatment.
At issue in the Sample Appeal is a combined treatment—cytoreductive surgery and
heated intraperitoneal chemotherapy. The NCCN guideline for colon cancer has
absolutely no opinion about this treatment, and makes no mention of it.
Let's see how Acme Insurance takes this guideline, and uses it to support their
denial.
NCCN guideline does not mention this treatment
Dr. Grisworld twists himself into a pretzel, to make it sound like the NCCN
guideline has decreed that this treatment is experimental:
"I have consulted with a physician who is board-certified in hematology/oncology.
He consulted the National Comprehensive Cancer Center Guidelines and related to
me that hyperthermic intraperitoneal chemotherapy is experimental in your clinical situation."
1. Griswold asks the opinion of a medical oncologist. Medical oncologists are
not experts in cytoreductive surgery. They are not surgeons. They do not
perform it, they don't understand it.
2. The oncologist consults the NCCN Guidelines.
3. The oncologist "relates" to Griswold that this treatment is "experimental."
Nice try, Dr. Griswold. There is one missing link, though. Nowhere in the NCCN
Guideline for colon cancer does it mention cytoreductive surgery or HIPEC, or say
that these treatments are experimental.
Five NCCN member institutions endorse cytoreductive surgery and HIPEC
After studying the NCCN guideline, I asked, "Who are these NCCN member
institutions?
I suspected that, while NCCN managed to find a medical oncologist at each of their
"leading cancer centers" that did not mention cytoreductive surgery, there would be
plenty of surgical oncologists at the same institutions who were in favor of this
treatment, who performed large numbers of these treatments.
I was right. Surgeons at five of the twenty-two NCCN member institutions had
signed the Consensus Statement endorsing cytoreductive surgery and HIPEC.
As a matter of fact, I happened to know that two of the NCCN institutions who
participated in writing this Guideline—MD Anderson and Roswell Park Cancer
Center—are high-volume centers for this treatment.
Busted. Acme Insurance has gone to great lengths to take thin air, and try to turn
it into proof. Don't let them get away with it.
*********
Digging into footnotes on a medical policy statement is the last thing in the world
that you want to do. This I know for sure.
However, if you do your due diligence on the insurance company's "rationale," it
will pay off in a big way.
The medical director of Acme who is reviewing your appeal is not going to lift a
finger to check out the references on Acme's medical policy statement. If you do it,
you will be one giant step ahead of him, and one step closer to winning your
appeal.
To purchase Laurie’s book and CD, click here: http://theinsurancewarrior.com/thebookandthecd.html
The insurance information presented on The Carcinoid Cancer Foundation website is a collaboration between the Foundation and Laurie Todd.
Direct linking to this information and/or unauthorized use and/or duplication of this material without express and written permission from The Carcinoid Cancer Foundation is strictly prohibited. See also Disclaimer.
Copyright 2010, The Carcinoid Cancer Foundation and Laurie Todd. |
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