Previous Excerpt 8 “Self-Funded Plans — A Battle on Two Fronts”

Have you already submitted an appeal? Did it have a cover page?

If not, your appeal was not as powerful as it could be.

Purpose

What is the purpose of a cover page? If you answered, “To list the date, my name, and my member ID number,” you would be wrong.

Every page of your appeal has a purpose, and the purpose is:
                                            

                                                INTIMIDATION

Let’s look at the sample cover page, and see how it intimidates.

In a traditional business letter, the “carbon copies” are listed at the end, on the last page. In my appeals, I list all of the addressees on the front/cover page. This is part of my delivery strategy.

The primary addressee of any appeal is “Joe Post Office Box” in the Appeals Department. We rarely have a name to whom we can address our appeal, and whenever have a street address.

How does giving no name and no street address benefit the insurance company?

  • There is no way for you to reach them directly.
  • You can’t get delivery confirmation from a post office box.
  • You can’t visit a post office box in person.

                             All patient and physician names have been changed,
                                         with the exception of Dr. Sugarbaker.

                                                SAMPLE APPEAL • COVER PAGE

Date: 1/1/11

From: John Q. Patient
Member ID #1234567
Group #00

To: Acme Insurance
P.O. Box 100
1000 First Avenue
Denver, CO 80230

Attn: Member Service Specialist

RE: URGENT EXPEDITED APPEAL

cc: Samuel Smith
President and CEO
The Acme Group

Jeff Jones, MD
Chief Medical Officer
The Acme Group

Dennis Dinsmore, MD, FRCPC
Chief Medical Officer
Acme Insurance of Colorado

Bill Barr
Executive Vice President, Health Care Operations
Acme Insurance of Colorado

William Wicks, MD
President
Colorado State Medical Association

Jennifer Johnson
Medical Management Analyst II
Regence Blueshield/Colorado Springs Field Office

Regence BlueShield
Everett walk-in facility
Archie Lamb

The Lamb Group/LLC

Did you ever notice that, when you talk to people at the insurance company, they never give you their last names? Plus, they rarely give you a direct working phone number to call them back.

It’s all about control. You can’t call them, but they can call you.

All dealings with your insurance company are a strategy game. They are doing all they can to keep control, and you are doing all you can to regain control.

At every step of the appeal process, Acme Insurance will try to put you back into waiting mode: “Wait for our letter … wait for our call … wait till we decide to decide.” Don’t call us, we’ll call you.

Do not let this happen. If they control the process, they will wait until the day AFTER your scheduled surgery date to make a decision. There is nothing better for the insurance company than having it be too late. If the decision comes too late,you will either die or get better on your own, and stop pestering the insurance company.

It’s also about no accountability. If I promise you something by phone, nobody is listening in, and you do not have my last name or phone number. I can forget my promise, ignore you completely, and there will be no adverse consequences for me.

I had a particularly fierce battle with an insurance company in Florida. They made full use of all of the control and evasion techniques inherent in the appeal process.This was an urgent, expedited appeal, with lifesaving surgery scheduled the following week. I pursued my usual delivery strategy—faxing, emailing, or snail-mailing eight copies of the appeal document to key decision-makers at Acme of Florida insurance.

Acme of Florida did their best to overcome my strategy, saying …

“The 48 hours doesn’t start until we receive the appeal. We don’t receive the appeal until we open the post office box. We only open the post office box once a week.”

“Somebody at Acme of Florida signed for a copy? What is his name? We never heard of that person, he doesn’t work here.”

Three of the executives that I faxed it to suddenly went on vacation for two weeks.

So, you see … our cover page has to be carefully crafted. It’s your job is to wrest control back from the insurance company. And to make sure that they acknowledge receipt of your appeal, that they immediately start working on it, and that they make their determination in a timely manner.

The Power of Names

The job of Acme Insurance is to withhold names. Customer Service representative swill not tell you their names, and they will not tell you the names of any higher-ups who could actually approve your treatment.

Names are power. If they won’t give you names, you will search, and find the names yourself. And put them on your cover page.

Let’s look at the names on our carbon copy list. Once we understand who the yare, and why they are important, you will be able to find the same key decision-makers at your insurance company.

1. Samuel Smith
President and CEO
The Acme Group

The president or CEO is the highest executive in the food chain. John Q. Patient’s insurer is Acme Insurance of Colorado, and The Acme Group is their parent company. Find the president and/or CEO at your insurer’s headquarters, and put his name first.

2. Jeff Jones, MD
Chief Medical Officer
The Acme Group

The highest-level insurance executive—the person who could approve your treatment with one stroke of his pen—is the medical director, or the chief medical officer.

“Chief Medical Officer.” What a title. Sounds like the commanding officer in the Insurance Army.

In this case, John Q. Patient’s insurer is Acme Insurance of Colorado, which is a subsidiary of The Acme Group in Los Angeles. In other words, the headquarters of his insurer is The Acme Group. Dr. Jones is the highest executive who is directly concerned with approving treatments, so his name goes first.

3. Dennis Dinsmore, MD, FRCPC
Chief Medical Officer
Acme Insurance of Colorado

Dr. Dinsmore is the highest medical director at Acme Insurance of Colorado, which is John’s local insurance company. Be sure to use the correct titles for these worthies. It makes you seem like some type of insurance or medical insider.

4. Bill Barr
Executive Vice President, Health Care Operations
Acme Insurance of Colorado

Find a suitable vice president to send your appeal to. Health Care Operations, Utilization Review, Quality Management will all do. If your medical directors or CEOs don’t take action, the vice president will look at your cover page, see that his boss the CEO has received a copy, and will get busy on your appeal.

5. Brian Wicks, MD
President
Colorado State Medical Association

Medical societies are powerful groups of physicians, who join together to bring the biggest, baddest, most successful lawsuits against health insurers. Most people haven’t figured this out. Copy the highest executive at your state’s medical society, and Acme Insurance will think that you are a doctor, or an insurance insider.

6. Jennifer Johnson
Medical Management Analyst II
Acme Insurance of Colorado/Colorado Springs Field Office

Insurance companies have all kinds of fancy names for case managers. This person is a case manager involved in John Q. Patient’s appeal. The case manager looks at the cover page, and sees that his superiors all the way up to the CEO have received copies of this document. Gee, do you think that he will get right to work on your appeal?

7. Archie Lamb
The Lamb Group/LLC

People ask me, “Should I threaten the insurer with a lawsuit.” No. They have one hundred lawyers to your one lawyer.

People also ask me, “Should I hire a lawyer?” No. That costs money. Why not simply copy the perfect lawyer on your appeal—a lawyer with a name that they will recognize?

After I had studied a few multi-million-dollar class action suits against insurance companies, I realized that the lead attorney was always the same guy: Archie Lamb.

I thought, “Why should I keep looking for names of lawyers to put on appeals? I will just use Archie Lamb on every appeal from now on.

Why pay money for an attorney, when you can call on the finest, most expensive legal representation for your appeal—just by including his name on your carbon copy list.

Don’t actually send a copy, just include his name. Archie Lamb is a name that your insurer will recognize. If you know about Archie Lamb, you must be some kind of insider.

Secret Search Strategies

When I decide to write an appeal, the first thing that I do is to spend a four or five hours searching for just the right decision-makers to send the appeal to—and their contact information.

In the process, I learn quite a bit about my opponent. Is Acme Insurance fairly accessible? Is it relatively easy to track down their highest executives? Or does it appear that they have dedicated themselves to keeping me out, and protecting their officers from insured people at all costs?

You need to find names, titles, phone numbers, and personal email or fax addresses for the highest executives at your insurance company. Acme Insurance is doing everything in their power to keep this information from you, because names = access, and access = power.

Finding hidden medical directors is both a science, and an art. I have perfected this art through four years of writing appeals.

Find the CEO

Let’s say that I am looking for the higher-ups of Acme Insurance of Indiana, whose home office is in New York.
Don’t make things harder than they have to be. Start with the insurance company’s website. Wander around and look for the “Leadership Team.” I have found priceless lists of top executives this way.

If you don’t readily find the leadership team on the home page, and there is a search feature, try searching for “leadership team, ” “president,” “CEO,” “vice president,” and “medical director.” If none of that nets you names and titles, go googling.

I always start at the top. Let’s search for the CEO of Acme in New York.

You may have to experiment with several different titles. The top executive of an insurance company may be called “CEO,” or “president.

I start by googling “president acme new york 2009.” Title, insurer, city, current year. I learned to add the current year, because I want to find the current medical director. If I don’t specify a year, I have to wade through all sorts of former presidents, CEOs, or medical directors.

Executives of insurance companies are public people, to some degree. They are interviewed for newspaper articles, they attend conferences, they chair meetings. This is where you will find their names and contact info.

If I get no hits for “president,” I will try “CEO acme new york 2009.” Eventually I get a hit, from a newspaper piece. His name is Arnold Schwatz, President and CEO.

Now that I have the name, I can search for the phone number, fax number, and email address. I don’t want the generic phone number or fax number for the home office—that’s not going to get me any action. I want to reach Arnold Schwartz directly.

I google, “arnold schwartz acme fax email phone.” Sometimes it is as easy as that. If nothing comes up, I will cut it down to “arnold schwartz acme fax,” and the fax number will pop up. Or “arnold schwartz acme phone,” or “arnold schwarz acme email.”

If I absolutely cannot find personal contact info, I will settle for the fax number of the office. But I won’t settle too often, as I want to make sure to be able to contact most of my addressees directly.

When I am zeroing in on the contact numbers, I may have to look through five to ten pages of search results. If you are willing to put in the time, you will eventually track down all of the key people who will work together to reverse the denial, and approve your appeal.

Zoominfo.com

Once I have the name, title, and location, I find a lot of contact information on www.zoominfo.com.

Zoominfo.com is a database of businesses, employees, and business executives. Unlike the traditional business directories like Spoke’s, Zoominfo includes a list of Internet references to the employee for whom you are searching.

For some reason, the search results on Zoominfo contact more personal contact information than other search results. Wade through them. In a cached file, on the third page of hits, you will find the personal phone or fax number for your target.

Delivery Strategy

We now understand that a cover page is not just a list of names. It is a carefully crafted first strike in the strategy game—designed to convince Acme Insurance that you are a force to be reckoned with.

I call my delivery strategy “poking the stick into the hornet’s nest.” Stir them up, get them all excited, throw them off their game.

When the appeal is written, polished, and ready to go, I proceed to the local copy center, and have two paper copies made. Finally, I have them spiral bound with a clear front cover, and dark blue back cover.

I have typed labels and prepared envelopes, and I head to the post office, where I Express Mail one copy to the Appeals Department, and one to a medical director. The rest of the copies will be faxed or emailed.

In the evening, after working hours, I will fax and email the rest of my copies to the remaining addressees.

Why do I fax in the middle of the night? If I start faxing a 32-page document during working hours, they are going to turn off the fax machine. Call it Laurie’s Stealth Fax Attack.

The people on your list are well-protected from troublesome patients like you. They have never seen an appeal like yours. They will all arrive at work in the morning, and have a nice clean copy of your thirty-two page appeal document on their desk.

I have also found a few of their private phone numbers. The next day, I will call ever so politely, and ask, “Have you received my urgent, expedited appeal?”

We see what lengths that insurance companies have gone to lose, shelve, or otherwise ignore appeals. My delivery strategy is my all-out effort to block their”we didn’t get it” strategy.

Arnold Schwartz, the CEO, will glance at your cover sheet, and immediately see who else has received your appeal. No appeal has ever reached his fax machine before, and he has never seen an appeal like yours.

The others will see that Arnold, their fearless leader, has received it.

My goal is that, after seeing all of the scary, embarrassing, legally troubling titles in the table of contents, they will immediately start calling each other, and things will start to happen.

Before they know it, they will have approved your appeal, and you will be on your way to your lifesaving treatment.

Next Excerpt 10 “Table of Contents — Frontal Attack”
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