Previous Excerpt 13 “Insurance Law — Powerful Ammo”
Every word in your appeal has a mission, and the mission is to INTIMIDATE. The story of your medical treatment is no exception.
The purpose of telling your medical story is not to—tell your medical story. They have your medical records; they already know all about your medical treatment.
When you tell your medical story in your appeal, it needs to be transformed into your Bad Medical Story.
What is the Bad Medical Story? It is a cool, blow-by-blow rendition of all of the things that your Acme Insurance doctors did wrong: the misreading of tests, the misdiagnoses. The wrong surgeries, the bad information. And, most importantly, all of the mistakes they made which reduced your chances of a good outcome.
The purpose of sharing the Bad Medical Story is two-fold:
- To prove with facts that there is no appropriate treatment in the Acme Insurance network. If you want to get out of network for treatment, you need to show how ineffective and even harmful your in-network treatment has been. If the treatment has been denied as “experimental,” you need to show that it couldn’t be any worse that the treatment that you have been getting from your Acme doctors.
- To unveil, in the most innocent way, a story that is embarrassing at best—and malpractice-worthy at worst. In other words, if they don’t pay for your treatment in a timely manner, there might be some legal unpleasantness.
In my estimation, no part of your appeal is more powerful than the Bad
ACME DOCTORS OFFER PALLIATIVE CARE ONLY
Diagnosis 1: “It’s Nothing.”
In December 2008, I began experiencing abdominal pain and severe cramping. On 12/20/08, Dr. Andrew Anderson, my Acme Primary Care Physician said, “I’m sure it’s nothing.” He scheduled me for an ultrasound of the pelvis.
Diagnosis #2: “Everything is normal.”
On 2/12/09, the ultrasound was performed. The technician said, “I am having a really hard time seeing the structures, because there is so much gas in the bowel.” She asked me to push down on my abdomen, to “get the gas away from the
Dr. Anderson’s office called to report, “Everything is normal.” When I later read the report, it stated that there appeared to be a “hypodense 2.5 cm. mass adjacent to the appendix.”
The severe pain continued.
Diagnosis #3: Changes in Bowel Habits
I returned to my PCP, who recommended that I be seen by Gastroenterology
Associates (also part of the Acme plan). I met with Dr. Matthew Masterson on 3/2/09. He scheduled me for a routine colonoscopy; he stated that the colonscopy had nothing to do with my symptoms.
Dr. Masterson listed the reason for the colonoscopy as “changes in bowel habits,’” even though I had not experienced any constipation or diarrhea. The colonscopy report noted hemorrhoids, and also “moderate to severe sigmoid diverticulosis.”
Diagnosis #4: Irritable Bowel Syndrome
Dr. Masterson noted on his report that he would treat me with a high fiber diet and continue to follow me for lower abdominal cramps. He continued, “I have started her on Levbid 0.375 mg in the office and will follow her clinical response for these pains, which are suggestive for irritable bowel syndrome.”
The severe pain continued.
On 5/1/09, I met again with Dr. Masterson, and told him that the pain had not lessened, and that the high fiber diet did not seem to be having any effect. He said, “I am 99% sure that this is irritable bowel syndrome. But, if you are so concerned, I will agree to schedule a CT scan of the abdomen and pelvis.”
Diagnosis #5: Mass … first you see it, then you don’t
On 5/14/09 the CT scans were performed. The report noted a “low attenuating mass related to the posterior right hemipelvis measuring approximately 4.5 cm,” and also some free fluid. An MRI was recommended. Also, it was noted that “a pelvic ultrasound had been performed on 2/12/09, which showed no mass.”
Diagnosis #6: Appendicitis
The MRI of the pelvis was performed on 6/1/09 at Brick Imaging, another Acme provider. After the scan was completed, the radiologist asked me to go back to Denver Diagnostics and return the same day with the film of the CT scan. Her report notes “no adnexal mass,” but that “the appendix appears thickened, masslike in appearance.”
Diagnosis #7: Appendiceal Malignancy
The second radiologist noted: “ … appendicitis with appendicolith are identified.”
On 6/13/09, Dr. Masterson contacted me at my office, and told me that I needed to report immediately to the ER, that I had an inflamed appendix which needed to be removed. I was admitted to Monroe Medical Center for an appendectomy, which was performed by Dr. Jeffrey Hart.
Acme surgeon says, “Get to an expert outside of Colorado.”
During his bedside visit the morning following surgery, Dr. Hart informed me that I had cancer that had spread throughout the peritoneal cavity. The pathology would confirm the site of the cancer. Dr. Hart said, “If I were you, I would seek treatment by an oncologist outside of Colorado.” In other words, the Acme-contracted surgeon told me, in no uncertain terms, to get to an expert—an expert outside of the Acme network. Finally, on 6/21/09, I was correctly diagnosed with metastatic adenomucinosis, with carcinoma of the appendix with intra-abdominal spread.
Acme Medical Oncologist says, “Get to Dr. Sugarbaker.”
The following week, I contacted an in-network oncologist, Dr. William Ward, who informed me that, while he could provide me with systemic chemotherapy, it would have little impact on this disease. He told me that, in his opinion, I needed to see Dr. Sugarbaker in Washington, D.C. He went on to say that he would write a letter to that effect to Acme. He expressed his confidence that, due to the rarity and aggressiveness of this cancer, Acme would cover it completely as they would an in- network case. (Att. x, Dr. Ward’s referral letter)
Most people don’t realize that they have a Bad Medical Story. My theory about this is that we are so used to trusting doctors—to giving them the benefit of the doubt— that we mentally edit out any illogical, inappropriate, or ignorant things that they may say.
Now is the time to zero in on those lame or dangerous remarks, and put them in your appeal.
What to leave in, what to leave out
A Bad Medical Story should be one to two pages. A complete recitation of your treatment would probably take twenty pages. What belongs in the Bad Medical Story?
Read my sample again. I want to give the impression of an army of in-network doctors, bumbling around like buffoons. Ignoring my symptoms, while the cancer advances unchecked.
Don’t list every doctor visit. Don’t tell everything they said, or every drug that they prescribed. Before you start writing, make a list of the “highlight happenings” of your medical treatment. In other words, surgeries (and all of the inaccurate and untrue things they said after the surgeries), major diagnostic tests (and their misreading of the tests). Bad advice as to what you should do about your disease or condition.
I especially like to put really cheesy, inappropriate remarks into Bad Medical
Stories. In one of my recent cases, the in-network surgeon said, “Hey, I could do a cytoreductive surgery if you want one. I did a few of them, several years back. But you are my friend, and I wouldn’t put my friend through that.” Embarrassing.
How about this one, “I hate doing these surgeries. I wish that they would stop sending these people to me.”
Or how about this gold nugget, “I’ve done twelve of these. I don’t know how the patients are doing. Don’t know, don’t follow them.”
If your in-network doctor says something really outrageous—he has just given you a gold nugget for your appeal.
Stop protecting your in-network doctors
Sometimes my helpees have a little resistance to the Bad Medical Stories that I write for them. They are a little squeamish about going all the way in making their surgeons, oncologists, and primary care physicians sound like the Three Stooges.
Why do we have the urge to protect our in-network doctors? I believe that it boils down to three things:
- They have treated us in our hour of need. We are bonded with them.
- We are used to respecting doctors. We look up to them.
- We are afraid that they may retaliate. We fear them.
Yes, they have treated you. But they haven’t cured you, and they haven’t gotten you where you need to go. It is time to shift your loyalties to your out-of-network expert of choice, look out for yourself, and move on.
It’s time to stop respecting all doctors, at all times. We appreciate that they are all went to medical school. Beyond that, we only respect them if they deserve our respect. If they deserve our respect, but they don’t help us, we move on.
It is possible that your in-network doctors are actually in favor of your requested treatment, and are helping you as best they can. However, if they said anything inaccurate, or anything that would lessen your chances of a good outcome—it belongs in your Bad Medical Story.
Your in-network doctors may be very competent and caring physicians. However,if you want to get out of network for lifesaving treatment, you are going to have to expose all of their mis-steps in your appeal.
Create embarrassing titles
Tell an embarrassing story with your titles. Use your titles to guide them into the absurd tale of your in-network treatment. The patient in this story told me that they had given her seven different diagnoses. I found this appalling, and shined a spotlight on it with my titles:
Diagnosis 1: “It’s Nothing.”
Diagnosis 2: “Everything is normal.”
Diagnosis 3: Changes in Bowel Habits
Diagnosis 4: Irritable Bowel Syndrome
Diagnosis 5: Mass … first you see it, then you don’t.
Diagnosis 6: Appendicitis
Diagnosis 7: Appendiceal malignancy
With the right titles, a boring list of doctor visits becomes a smart-bomb of
In Chapter 5, we talked about the power of names. When you talk to a person at the insurance company, they will never give you their last names. When you prepare your appeal, you will spend however long it takes to find names and titles for the highest-level executives at the insurance company.
Names are power. Names make things happen.
Name the name of every in-network doctor who appears in your Bad Medical Story, and give the dates when you saw them. By naming them, you hold them accountable for everything they did, and everything they said.
And, remember—in my sample story, I never make any remarks or editorial
comment about how bad, unfair, unjust, or outrageous the treatment was. Just tell the story. Don’t tell your readers how to feel.
The effect will be much more powerful, if you let the bigwigs who are reading your Bad Medical Story figure out for themselves how bad it is.
I seem to be the first one to think of putting direct quotes in appeals.
For me, it’s a no-brainer. I am telling a story here. I want my listeners to be
plunged into the story, and come out on the other side eager to approve my
I love direct quotes. They put the reader into your appeal. They make it real.
Consider the difference between these two statements:
- In December 2008, I began experiencing abdominal pain and serious cramping. On 12/20/08, Dr. Andrew Anderson, my Acme Primary Care Physician said that it was nothing.
- In December 2008, I began experiencing abdominal pain and serious cramping. On 12/20/08, Dr. Andrew Anderson, my Acme Primary Care Physician said, “I’m sure it’s nothing.”
First statement, wimpy. Second statement, smart-bomb of intimidation.
All it took was one direct quote.
People sometimes fear what will happen if their in-network doctors see their names and unwise words splashed all over your appeal.
In order to win an insurance appeal, we need to throw all caution to the winds, and let go of all fear. The insurance battle is a strategy game. The minute you give in to fear, you lose.
When I explain to you what happens to these appeals after they leave our hands, you will have no more reason to fear.
Rest assured—your doctors will never see a copy of your appeal.
In all of my forty-four appeal victories, we have never had blow-back from doctors, and we have never had retaliation from an insurance company.
Quite the contrary. Once your insurer gets done dealing with your blockbuster appeal, they will know for sure that you are a force to be reckoned with. And they will treat you like a V.I.P. ever after.
What happens to your appeal after you send it? This is a document so shocking, so embarrassing, so intimidating to your insurer that they want to dispose of it as quickly as possible, and to pretend they never saw it.
After receiving your appeal, Acme Insurance will either pay or not pay. Period. No reprisals, no recriminations. For ever after, they will roll out the red carpet, hand you a latte, and treat you like the respect-worthy person that you are.
Next Excerpt 15 “In-Network Doctors — Remove Their Lieutenants”
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