The Insurance Intelligencer
7/16/07

The Three Most Powerful Weapons

There are many components to an insurance appeal, and they should all be present to ensure success. The appeal must not be a “letter,” because a letter is not extensive enough, not substantial enough to be persuasive. No letters, they don’t carry enough weight. It must be an APPEAL DOCUMENT, with a title page, table of contents, cover letter, bullet list of facts, attachments, scary mistake-filled medical story, peer-reviewed studies, resume of your doctor-of-choice, cost comparison, and blockbuster conclusion with a call to action.

The facts are important, the tone of your writing (solid as a rock, totally dispassionate) is important, every detail of the appearance of your document is important.

After participating in a number of these successful appeals, I feel that there are three elements of the appeal that close the deal better than any other. They are the linch-pins of your appeal, they must be there, and they must be polished to perfection, and packed with power.

1. The Quotation Mark

People often call me on the phone and tell me about the outrageous things that their doctor or insurance company representative has said to them. Some examples ...

  • “Don’t even bother to appeal, because there is zero chance of it’s being accepted.”
  • “At your age, we don’t need to find out the cause of your rectal bleeding ... we will just give you a transfusion once a week.”
  • “There is no treatment for your disease.”
  • “Yes, we have paid for that surgery before. We paid for it by mistake, so we won’t be paying for yours.”
  • “We lost the fax, we lost the email, the letter got lost in the mail.”
  • “There are NO good outcomes with that surgery (when the only bad thing about the surgery is that it is out of network).”
  • “You don’t need any more surgery (when you really do).”
  • “You need surgery right away (when you ought best wait to see an expert).”
  • “Your husband is one of our highest-paid executives. If we funded the surgery for you, other employees would be jealous.”

These are all true examples. When anyone associated with your insurance company – doctor or bean-counter – says something outrageous, they have just handed you a nugget of solid gold.

There is nothing more powerful as a naked reporting of what goes on behind closed insurance doors.

Don’t tell me these things ... FIRE UP THE QUOTATION MARKS, AND PUT THEM IN YOUR APPEAL!

2. The Carbon Copy

You write a beautiful appeal document – chock full of facts and intimidating medical mistakes, loaded with proof. Then, you send as directed by your insurance company, to “Mr. Joe Post Office Box.” You might as well throw your appeal in the trash. Why should Mr. Post Offfice Box help you out? There is nobody to check up on him, no accountability.

You must lavish time and effort on the list of important people to whom you will send a copy of your appeal. You will craft your own list, but I have some suggestions. Always copy the Medical Director of the insurance company. Sometimes it takes a little digging to find these people ... your appeal will have more impact just because they know that you were capable of finding a Medical Director. Then, copy a good list of executives at the insurance company. Copy your state’s Insurance Commissioner. Don’t really send him a copy, he doesn’t want to see your appeal. You just want the insurer to know that you know his name – and have probably contacted him. If this is a group policy through your employer, contact the highest HR executive at your company.

Did you find any lawsuits against your health insurer while you were Googling? Copy the attorney who won a lawsuit against them ... this is a name that they will recognize. Has your insurer been investigated by the Attorney General of your state? Copy him – another familiar name for your insurer. Copy the head of your state’s medical board.

Be realistic with your cc’s ... they know that Oprah isn’t going to be participating in your appeal.

The intention is to have your scary appeal land on many powerful desks at once, and to have many higher-ups picking up the phone to call your addressee. Now, Joe Post Office Box cannot ignore your appeal.

3. The Cost Comparison

This really is all about money. Your insurer has denied your treatment not because it is experimental, investigational, not medically necessary, or out of network. They have denied because they don’t want to pay for it.
The best way to nip this unspoken objection in the bud is to simply prove that the treatment you are proposing will COST LESS than the treatment your insurer is proposing. Since they are probably proposing no treatment at all, and you will get worse without any treatment, this shouldn’t be too hard to prove.

Spelling out all of the terrible expensive things that will happen to you if you DON’T get the treatment serves three purposes:

  1. It puts the kibosh on their true motivating objection: We are denying your treatment to control our costs.
  2. It serves notice to your insurer, in a very subtle way, that you understand what is behind this denial – money.
  3. You have already told about your past malpractice-worthy medical story. With the cost-comparison, you get to tell your possible future malpractice-worthy story – if they don’t pay.