The Insurance Intelligencer
4/15/08

“The Doctor Wrote my Appeal”

When I first heard this, I was baffled. I wondered ...

  1. Whose doctor would write an appeal?
  2. What kind of an appeal would a doctor write?
  3. Why would a patient trust anybody but themselves to write an appeal?

If you had asked me three years ago, “Why don’t you have your doctor write an appeal?” ... I would have laughed till I cried. Not only weren’t my local doctors interested in writing an appeal, they were dead set against me getting any treatment at all, saying ...

“You don’t need any further treatment.”

“There is this Dr. Sugarbaker. However, if you went to him, you would be disabled.”

“There is no treatment for your disease. And, even if there were, they wouldn’t pay for it.”

Like I would trust any of these individuals to write an appeal for me.

I have learned much in the past three years. When people find themselves in Insurance Denial-Land, their first reaction is to call the insurance company. Once they figure out that they aren’t getting anywhere with their insurance company by phone ... they call their doctor.

Once upon a time – before the advent of Managed Care in the 1970’s – your doctor would have been the one to call when the insurer said “no.” Back then, your doctor’s practice was an independent entity. It was his job to find the best treatment for you, to request it of the insurance company, and to persuade them to pay for it.

Back in 1970, in their quest to control skyrocketing medical costs (How well has that worked?) the insurers came up with a brilliant concept. Let’s build a building, put all the doctors in it, pay them a salary, and put a contract in place that says that the INSURER gets to decide what treatments get paid for.

Voila, the HMO is born. PPO, POS – whatever type of insurance you have, your doctor is contracted with the insurance company, and you live according to the principles of managed care.

There are two types of doctors that you will encounter: Doctors who are contracted with your insurance company (in-network), and doctors who are not contracted with your insurance company (out-of-network). Let’s see what happens when each type of doctor writes your appeal.


In-network doctor writes appeal

He is bound by contract to your insurance company. Therefore, it follows that he is not in the best position to mount a powerful appeal to make the insurer pay for something they don’t want to pay for.

Sort of like a quarterback going for a touchdown for the opposing team.



Out-of network doctor writes appeal

The doctor who is not contracted with your insurance company (often your expert of choice) has no influence whatsoever with the insurer.

What repercussions are there if an out-of-network doctor asks for a treatment for you, and the insurer still says no? None.

See where I am going with this?

The only person who has any traction with your insurance company is YOU.


What kind of appeals are doctors writing?

In 99.9% of cases, they are not writing appeals at all. Best case scenario, they write a one-page letter saying, “The patient really needs this treatment.” More likely, they have a form letter in their files that says, “The patient really needs this treatment.”

There is an exception to every rule, of course. I have met one doctor who personally engages in appealing insurance companies. It is very frustrating for him, and it takes away from the highest and best use of his time, which is performing lifesaving procedures.

I have advised him more than once to buy a supply of my books, issue one to each new patient, and get the patients on board to write their own appeals.

When your life is on the line, is a one-page form letter good enough for you?


Laurie the I.W. speaks to an Appeals Coordinator

A prospective cyberknife patient contacted me ... her first two appeals had failed. I asked, “What did you say in the first two appeals?” “My doctor did the appeals,” she answered.

She then suggested that I speak to the Appeals Coordinator. I eagerly anticipated speaking to someone who actually gets paid for what I do.

I asked the paid appeals expert, “What did you put in the first two appeals?”
“Well, it was a letter,” she replied.

“How long of a letter?” (Laurie)

“One page and some articles.” (Appeals Coordinator)

“How many articles?” (Laurie)

“Two.” (Appeals Coordinator)

Two. I almost fell off my chair. Since I don’t mince words these days, I said, “When I write the third appeal, the letter will be twenty pages long. I will attach at least twenty-five peer-reviewed studies and articles (specifically about cyberknife and liver tumors). I will go to the FDA website, and find written proof that the cyberknife equipment is FDA-approved, and exactly what kind of FDA approval it has. Then, I will go to the CMMS (Center for Medicare and Medicaid Services) website, and find the written evidence that Medicare is reimbursing for cyberknife for liver lesions.

Then, I will go out into the online support groups, and find thirty cases where major insurance companies have paid for this before (precedent).”

Bottom line? Do not leave it to your doctor to write your appeal.

Laurie Todd