Previous Excerpt 9 “Cover Page — First Strike”

Just as a cover page is not just a list of names, a table of contents is not just a list of chapter titles.

First, your addressees will see to whom you have sent your appeal. Next, they will flip to the table of contents, and see the highlights of your case.

Purpose

The table of contents is where you come out swinging, show that you understand what insurance denials are all about, and point out the weaknesses in the insurance company’s position.

The purpose of a table of contents is not to show which chapters start on which pages. The purpose of your table of contents is to INTIMIDATE.

Lay out your case in a bold, logical, fearless manner, and they will read on—and get busy deciding your case, and approving your treatment.

The table of contents is the teaser that gets a busy executive at the very top of the food chain to stop, look, and consider your appeal. Think of the table of contents as the carnival barker standing out in front of your appeal, giving his pitch, talking people into the tent, into the show.

Your table of contents needs to:

  • Address the reason for the denial
  • Show that the insurance company goofed
  • Demonstrate that you have scientific evidence
  • Use their own words against them

Let’s take a look at the sample table of contents.

Table of Contents

Appeal letter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-3
Cytoreductive surgery and HIPEC

The treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

The outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

The scientific proof . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-7

Acme Violates Colorado Revised Code

First-level review violates Colorado Rev. Statute 10-16-113………….8

Acme’s “Rationale for Decision” not supported by facts

Acme doctors offer palliative care only . . . . . . . . . . . . . . . . . . 9-10

Acme surgeon not qualified to perform cytoreductive surgery . ..11-12

Acme expert refers me to Dr. Sugarbaker . . . . . . . . . . . . . . . .13-14

Dr. Sugarbaker is an expert often used by Acme . . . . . . . . . . . 15-16

Sixty-five cases of precedent . . . . . . . . . . . . . . . . . . . . . . . . 17-23

This treatment is not experimental by Acme’s own definition . . 23-26

This treatment is medically necessary, by Acme’s own definition.27-30

Acme denial letter offers spurious “proof”

Hayes declares their assessment out of date . . . . . . . . . . . . . . . 31

NCCN offers no opinion on this treatment, NCCN members embrace it 32

Attachments

Att. 1: Dr. Sugarbaker’s treatment plan

Att. 2: Hayes letter declaring their Assessment Report out of date

Appearance Matters

I have seen all manner of confusing and unreadable tables of contents. If your table of contents confuses and confounds the reader, your appeal is sunk.

Make it easy on your reader. You want to entice him into your appeal, hit him upside the head with your powerful arguments, embarrass him with his unwise or illegal blunders, then ask calmly that he do the right thing.

Consider the look of this table of contents. It is organized, clean, and balanced.

The points are organized into sections, and all of the section titles stand out in boldface.

The boldface titles draw the reader down to your individual arguments.

Use one typeface throughout the appeal—Bookman Old Style, 11 point. Boldface is only used for titles, so as not to confuse the eye. No underlining, it is distracting.

Double-space between sections, 1.5 lines between individual items.

I use a line of periods with one space between them to connect the titles with the page numbers. Make it as easy as possible for your reluctant readers to find your powerful arguments.

The page numbers should line up at the right margin. Nothing is more annoying than meandering page numbers.

A table of contents should not be more than one page, and it should fill as much of that page as possible.

Intimidating Titles

You have already hit Acme Insurance with your “carbon copy list.” They know that your appeal is winging its way to the highest-level secret decision-makers at the insurance company.

With the table of contents, you want to intimidate them enough so that they actually read and consider your appeal.

Take another look at the sample table of contents. Which of these section titles will most intimidate your insurance company?

“Acme Violates Colorado Revised Code”
“Acme’s Rationale for Decision not supported by facts”
“Acme surgeon not qualified to perform cytoreductive surgery”
“Acme denial letter offers spurious ‘proof'”

“Spurious” means “illegitimate, forged, fraudulent.” Using it makes you sound like a malpractice lawyer.

See where I’m going with this? A table of contents is not just a list of titles. It is your opening salvo in the battle to win your lifesaving treatment.

Dream up the most outrageous, in-your-face, shocking titles that you can think of, and put them in your table of contents.

After you write each title, measure it against Laurie’s Terror Test:

Will this title force my insurer go immediately to the section, and read it?

Attachments

You will notice that this appeal, while it is for a very complicated, sophisticated cancer treatment and chemotherapy, includes only three attachments.

I used to create appeal documents with twenty-eight pages of original verbiage, and fifty pages of attachments. The list of attachments took up an entire page. At the time, I believed that an appeal needed to intimidate by its very size and weight.

I have since learned that nobody reads attachments. Insurers are not going to delve into sixteen-page scientific medical journal articles. They are used to seeing articles and lists of articles. So used to it, in fact, that they completely disregard them.

In my most recent appeals, I have taken a different approach. If I want Acme Insurance to consider a particular article or study, I sit down with my highlighter and READ the article myself. Predigest it for them, as it were.

I mark the most important “gold nuggets” from the article, and include them as quotes in the body of the appeal. If they are incorporated into the appeal itself, it will not be so easy for Acme Insurance to ignore them.

“Predigesting” the articles has an added benefit. If I step up to the plate, and actually read and comprehend the scientific proof for my treatment, I will sound like an expert, when I talk about it in my appeal.

Remember, we want Acme Insurance to suspect that we might be a doctor/lawyer/insurance insider. The more we know, and the more we understand, the more we will establish ourselves as a force to be reckoned with.

Next Excerpt 11 “Cover Letter — Opening Salvo”
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