Laurie the IW
10-09-2009, 04:10 PM
Laurie the Insurance Warrior here.
I have attached the "nutshell version" of my appeal strategy:
Laurie’s ten-step plan to a winning appeal<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
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An appeal is not a medical document. It is a legal document, meant to intimidate.
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Push the insurer to deny your treatment in writing. There are time limits on deciding appeals, but there are no time limits on issuing denials.
Write a full-fledged document. I’m talking title page, cover letter, table of contents, bullet list of facts, attachments, conclusion. Your appeal should be at least twenty pages long.
Do your research. You must be an expert on your insurer, your disease, your doctors, your treatment. You must be able to argue for your treatment like a champion debater.
Address your appeal to the right decision-maker, with carbon copies to other important people who will check up on him. Your life depends on it – don’t address your appeal “Mr. Joe Post Office Box.” The carbon copies are critical. If there is nobody to check up on your addressee, what is to prevent them from disregarding your appeal? Medical directors, insurance company executives, lawyers who have sued them successfully.
Purge all emotion from your appeal. Most people beg, plead, talk about their pain and anguish ... this will not advance your case. The minute you give in to feelings – especially anger or sarcasm – you have lost your power and lost your case.
Tell your own medical story, but don’t tell all. Just tell the things that the insurance doctors have done wrong. Lay it out in the most innocent way, so that they will think, “Danger, danger! We goofed!” The only reason to tell your medical story is to intimidate.
Qualify or disqualify all doctors. Be prepared to prove with facts that the doctor you choose to go to is eminently qualified, and the one who you don't want to go to is not qualified. Study the doctors involved; know everything about them.
Supply precedent. In other words, a list of cases where they have paid for this before. Even if they have called your treatment-of-choice “Experimental,” they have paid for it before. Join an online group for your disease, and call out for precedent.
Conclude with the cost comparison. This is all about money. You must prove to them that what you are proposing will cost less than what THEY are proposing.
Push the appeal along, pester them every day. Delaying is a tactic, delaying = denial. They will be very polite, “We lost the fax, he is on vacation, she hasn’t decided yet, wait for our letter, etc.” This will continue until you are either dead, or better and don’t need the treatment.
<o:p></o:p>
<o:p>Torpedos away!</o:p>
<o:p></o:p>
Laurie
The Insurance Warrior
I have attached the "nutshell version" of my appeal strategy:
Laurie’s ten-step plan to a winning appeal<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
<o:p></o:p>
An appeal is not a medical document. It is a legal document, meant to intimidate.
<o:p></o:p>
Push the insurer to deny your treatment in writing. There are time limits on deciding appeals, but there are no time limits on issuing denials.
Write a full-fledged document. I’m talking title page, cover letter, table of contents, bullet list of facts, attachments, conclusion. Your appeal should be at least twenty pages long.
Do your research. You must be an expert on your insurer, your disease, your doctors, your treatment. You must be able to argue for your treatment like a champion debater.
Address your appeal to the right decision-maker, with carbon copies to other important people who will check up on him. Your life depends on it – don’t address your appeal “Mr. Joe Post Office Box.” The carbon copies are critical. If there is nobody to check up on your addressee, what is to prevent them from disregarding your appeal? Medical directors, insurance company executives, lawyers who have sued them successfully.
Purge all emotion from your appeal. Most people beg, plead, talk about their pain and anguish ... this will not advance your case. The minute you give in to feelings – especially anger or sarcasm – you have lost your power and lost your case.
Tell your own medical story, but don’t tell all. Just tell the things that the insurance doctors have done wrong. Lay it out in the most innocent way, so that they will think, “Danger, danger! We goofed!” The only reason to tell your medical story is to intimidate.
Qualify or disqualify all doctors. Be prepared to prove with facts that the doctor you choose to go to is eminently qualified, and the one who you don't want to go to is not qualified. Study the doctors involved; know everything about them.
Supply precedent. In other words, a list of cases where they have paid for this before. Even if they have called your treatment-of-choice “Experimental,” they have paid for it before. Join an online group for your disease, and call out for precedent.
Conclude with the cost comparison. This is all about money. You must prove to them that what you are proposing will cost less than what THEY are proposing.
Push the appeal along, pester them every day. Delaying is a tactic, delaying = denial. They will be very polite, “We lost the fax, he is on vacation, she hasn’t decided yet, wait for our letter, etc.” This will continue until you are either dead, or better and don’t need the treatment.
<o:p></o:p>
<o:p>Torpedos away!</o:p>
<o:p></o:p>
Laurie
The Insurance Warrior