The Insurance Intelligencer
1/8/08

Case Managers, Patient Advocates, and Rapid Resolution Teams

Q: My insurance company says that they won’t pay for my treatment. First thing Monday morning, I am going to call the people at the insurance company who will fight for coverage for me.

A: Deep breath. Time for a paradigm shift.

Nobody at the insurance company is going to fight for coverage for you.

Your in-network doctor cannot win an appeal for you, because he is employed by the insurance company.

Your out-of-network doctor-of-choice cannot win an appeal for you, because he has no influence with the insurance company.

The only one with the power to make your insurer pay is YOU.

The only way for you to make them pay is the WRITTEN APPEAL.

When a treatment is denied, many get on the phone and call somebody with a job title such as: Case Manager, Patient Advocate, Reimbursement Specialist, Rapid Resolution Team.

If you go this route, you are running directly into the arms of the insurance company. These so-called helpers will be very kind, very caring. They will speak your name often during your many phone conversations. They will lull you into complacency, and they will often ask you to wait: “Just wait for our phone call, just wait for our letter. Wait, just wait, until Dr. Joe Post Office Box returns from his vacation.”

When will Dr. Post Office Box return from his vacation? One week after your surgery date.

All of this waiting. Delay = deny.

Heed the First Commandment of Insurance: “Pay as little and as late as possible, and you shall be blessed with higher profits.” By the time you get done waiting ... waiting for phone calls that never come, waiting for form letters that say “no,” waiting for fictional decision-makers to return from endless vacations ... you will either be dead, or all better.

Talking to the Case Manager is akin to talking to the IRS. Be very careful what you say, because your calls with them are being recorded. As with the IRS, don’t bare your soul, or say anything that jeopardizes your case.

Remember my cardinal rule: The only reason to call the insurance company is to find out where to write. Nobody ever changed a decision of an insurance company by talking to them on the phone.

Case Manager

One who is tasked with getting you to agree with the insurance company’s plan for you, and to keep you away from any and all decision-makers.

Patient Advocate

One whose job it is to explain to you why the insurance company won’t pay.

Rapid Resolution Team

One whose job is to never, under any circumstances, call you back.

If you have never needed anything expensive from your health insurer, you may think that I’m kidding. How I wish I were. After writing/editing twenty-eight winning appeals, certain patterns begin to emerge.
Big disclaimer ... people who work for insurance companies are human beings. Every once in a blue moon, a case manager or patient advocate steps out of line, does what they are not supposed to do, and actually helps somebody. When they do this, they are bucking the system. It is critical that you recognize this, cultivate this “insider” however you can, and protect them at all costs.

In my case, the “helpful insider” was a financial advisor in a windowless broom closet in the basement of the insurance company. I recognized a double agent when I saw one, and bonded with her as best I could. She told me about a little-known program where I could apply to get my deductible and out-of-pocket expenses paid by the insurer. Further, they paid my premiums for six months, and bought me a pair of glasses.
Of course, I had to fight for my lifesaving treatment without out any help – and with much hindrance – from my health insurer.

Go forth and be peaceful warriors. This is nothing personal.

It is simply your insurer’s job not to pay, and your job to make them pay.