Previous Excerpt 16 “Out-of-Network Expert — Bring in the General”
Precedent is cases where insurance companies have paid for your treatment before.
What is Precedent?
Precedent is not you saying, “Many insurance companies have paid for this before.”
Why should they believe you?
Precedent is not a list of insurance companies who have paid for this before. They won’t believe you unless you give dates, and name names.
There are three different categories of precedent:
1. Cases where your exact same insurer has paid
2. Cases where other “branches” of your insurer have paid
3. Cases where other insurers have paid
Your doctor can’t give you cases of precedent; there are laws against that. You are going to have to dig for it yourself.
I have won cases with no precedent. It was like winning a boxing match with one hand tied behind my back. I wouldn’t advise it.
Do your work. Find cases of precedent, and put them in your appeal.
Let’s look at the rest of the precedent). We will learn what precedent is, how to find it, and how to make best use of it in your appeal.
“But they called my treatment ‘experimental’,” you say, “How could they have paid for it before?”
If you are asking for a halfway legitimate medical treatment—your insurer has paid for it many times before. You will write a blockbuster appeal, and get it approved for you. The next patient who comes along will have it denied as “experimental,” and will have go through the same process all over again.
The only person who could possibly think that this is acceptable is a person who works at an insurance company.
How many cases do you need? Enough to win your appeal. In other words—more than one, and as many as you can.
I have seen appeals where people only used one case of precedent. Guess what the insurance company said? “Yes, we did pay for it once—but we didn’t mean to. We paid for it by mistake, ” or, “He had a different plan than you do,” or, “That was a one-time deal.”
Find at least six cases of precedent, and aim for an even dozen.
1. Where do I find precedent?
Do me a favor. Don’t call your doctor’s office asking for precedent. There are
serious medical privacy laws (HIPPA), and they can’t give it to you.
How I wish it were that easy. Finding cases where insurers paid before is very labor-intensive. However, it is well worth the effort.
We find precedent by joining online groups for our disease/condition, and
putting out the call.
Let’s say you have carcinoid tumors, you have requested an external pump to use with the drug Sandostatin, and Acme has denied it as “Experimental for this use.” You have read Acme’s Medical Policy Statement about the pump, you have studied their definition of “Experimental,” and you have familiarized yourself with Acme’s appeals procedures. Now it is time to join an online group for carcinoid tumors, introduce yourself, and put out the call.
Online patient support groups come in many forms: websites, listservs, and
Yahoo groups—to name a few. Find the most active groups, with the most
members, and post the following:
“My name is John Q. Patient, and I have Acme Insurance. Acme has denied my request for an external pump for Sandostatin. Has your insurance company paid for it? If so, I need your:
1. First and last names
2. Name of insurance company
3. Date of treatment
4. Doctor’s name
2. What is precedent?
Precedent is not you saying, “Many insurance companies have paid for this
before,” and precedent is not a list of insurance companies that have paid.
Why should they believe you?
Remember the power of names. You are going to have to prove that they have paid before by giving dates, and by naming naming names.
3. Will people give me their private information?
I have never had any fellow patient withhold it. We need and want to help each other.
4. Will I get in trouble for putting private information in my appeal?
HIPPA is a group of federal laws ensuring that medical information is kept
confidential, as it moves through the healthcare system. Violation of HIPPA
laws brings very serious consequences for the entities that are covered by them.
Who are the entities that are covered by HIPPA? Doctors and other medical
providers, health insurers, and third-party administrators (companies that
handle insurance billing).
I am not a doctor, I am not an insurance company, and I am not a third-party administrator.
I am a cancer survivor, gathering cases of precedent to help myself and other cancer survivors. I ask for their information to use in appeals, and I get their approval to do so.
I seriously doubt that Acme Insurance is going to sue me for a HIPPA violation.
5. What if there is no precedent for my insurance company?
Take another look at my sample precedent list. First, I list the cases where my own insurer has paid before. Next, I list the cases where other “branches” of my insurer have paid. Finally, I roll out the cases where other large insurers have paid, and where HMOs have paid.
Obviously, if you can find a case where your own insurance company—in your own state—has paid, that is the most powerful type of precedent.
However, I throw in all precedent that I can find, at all times, with the following disclaimer:
“We understand that these are all different insurance entities. However, this extensive list of approvals simply adds to the mountain of proof that this treatment is now standard of care for this disease.”
When it comes to precedent—use what you have. And use it to best advantage.
Your insurer denied your treatment because it was “Experimental”? Through your own due diligence, you have managed to discover that they have already paid for it a dozen times. As a matter of fact, they paid for it last week.
If nothing else convinces you to realize that the Insurance Emperor has no clothes, precedent should. There is no substance behind their denials. It is all bluff and bluster.
Here, in Sample Appeal Class, I am teaching you how to see through their bluff and bluster. First, clear away all the propaganda. Then, learn to fluff up your feathers, look big and intimidating, and turn the insurance company’s own words to your advantage.
Next Excerpt 18 “Experimental — Seize Their Weapons”
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