The Insurance Intelligencer
9/8/08

Carbon Copies

I just finished writing appeal number forty. The person for whom I wrote it asked, "Why do they ever agree to pay for these treatments? They really don't have to."

He is correct. All of the thirty-nine previous winning appeals were for treatments that were:

o Out-of-network, and the patient had no out-of-network benefit.

o "Experimental" as per the insurance company.

o "Not medically necessary" as per the insurance company.

Most people would be stopped by these objections. There was no reason why the insurers had to pay for any of them. However ... they paid them all. Every denial of care is a bluff, and every insurance appeal is a bluff.

Why do they then decide to pay? Two reasons:

I. The hidden intention of your appeal

I meticulously craft each of these documents to make the insurer suspect that you might -- just might -- be an attorney.

Insurance companies aren't afraid of you HIRING an attorney, they are afraid of you BEING an attorney. How come?

First, they have a dozen attornies to your one attorney, and they know that you could not afford to pay an attorney for the years that it would take to win your case. However, if you are an attorney, you can persist for years.

Second, if you have cancer and hire an attorney, they can seriously beat up your attorney in court. If, however, you are the insured person with cancer, and you are an attorney ... they can hardly beat up on YOU in court.

II. Who you send it to

Have you checked your benefits booklet for where to send an appeal? It is always a post office box. Even when the insurance company has a perfectly good street address, you send your appeal to a post office box. There are three good reasons for this:

-- You cannot send your appeal "signature required."

-- You cannot call, email, or otherwise pester the recipient.

-- The insurer controls when they receive your appeal.

Last June, we sent "urgent/expedited" appeal to an insurer in Florida. The insurer's time limit for deciding expedited appeals was thirty-six hours. Sounds good, yes? When the patient called Acme Insurance, saying, "I sent you an expedited appeal two days ago, " Acme replied, "We only empty the P.O. box once a week." Joke's on you.

They didn't get away with the time-honored P.O. box ploy, because I used my carbon copy strategy.


The Carbon Copy Stealth Attack

Every failed appeal that I have seen either didn't copy anyone on their appeal, or copied Oprah, Michael Moore, various politicians, or their doctors.

People, please! Carbon copies are critical to the success of your appeal. If I spend twenty hours writing an appeal, I will spend six hours searching for just the right people to send it to. The list of "cc's" is my opening salvo -- it goes on the cover page. I want my addressee to know right up front who else is receiving this masterpiece.

Quiz question: What is the purpose of carbon copies?

Answer: The same purpose as the rest of your appeal. Intimidation!

Do you really think that Acme Insurance will believe that Oprah, Michael Moore, or your congressman will read your appeal, and call Acme on the phone? Zero intimidation factor.

If your doctors works for the insurance company, he is in no position to intimidate the insurance company. If your doctor is not contracted with the insurance company, he has no influence with them whatsoever.

To whom should you send your brilliantly crafted smart-bomb of persuasive prose?


Medical Directors

Who really has the power to veto or approve your treatment? Who at the insurance company holds divine power over your life and death? The medical director.

Medical directors are not eager to be found by you. As a matter of fact, they employ all manner of clever ruses NOT to be found by you. Why? Obviously, these worthies do not want untidy, hollering, weeping cancer patients such as ourselves turning up on their doorsteps.

That is why you must find the medical director, and make sure that he receives a copy of your appeal.

You must outsmart the bureaucracy that would deny you access to this top medical decision-maker. The Internet has made this much easier for you; you will find him by diligent and creative Googling.

Better yet, find two or three medical directors, just in case one doesn't work there anymore. I find that medical directors of insurance companies don't last very long ... must be a very stressful job.


V.P.s at the insurance company

V.P. of Quality Assurance, V.P. of Healthcare Operations ... that sort of title. Once they see the Medical Director's name on your appeal, they will get right to work.


Executive Director of your state's medical society

Insurance companies are not intimidated by insurance commissioners. Most insurance commissioners have no teeth, and it is not their job to fight your denial of care battles for you. If you have an insurance commissioner on your "cc" list, Acme Insurance knows that you are not an insider.

Medical societies are much more intimidating to insurers. Why? Because medical societies are large, powerful groups of physicians. Who do you suppose brings and wins the multi-million dollar class-action suits against health insurers? Medical societies.

If you copy the director of your state's medical society, Acme Insurance will know that you are an insider.


Just the right lawyer

Whenever I face off with a new insurer, I check and see if there are any recent successful class action suits against them.

I read the lawsuit, then toss a little phrase into the appeal such as: "Since Acme had that unpleasantness about reimbursement last year, I'm sure that they will show total transparency in my case."

Finally, I skip to the end, and see who was the lead attorney on the case. I don't actually SEND him a copy of the appeal, just put his name on the "cc" list.

Major legal firepower -- for free.

I figure that that is a name they will recognize.

Laurie Todd