The Insurance Warrior

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"Between 2000 and 2003, seven in ten adults who were driven into debt by medical expenses HAD INSURANCE AT THE TIME" (Readers Digest, April 2006).

Among the many strategies which insurers use to deny care:

• The provider or hospital is "out of network."
• The treatment/drug/procedure is "experimental."
• The surgery/drug/procedure is "not medically necessary."

With Laurie's book, Fight Your Health Insurer and Win, you will learn how to leap these objections in a single bound.


Listen to my recent radio interview below.

Ask the Insurance Warrior
4/27/08


"The Doctor Wrote my Appeal"

When I first heard this, I was baffled.  I wondered ...

    1.  Whose doctor would write an appeal?
    2.  What kind of an appeal would a doctor write?
    3.  Why would a patient trust anybody but themselves to write an appeal?

If you had asked me three years ago, "Why don't you have your doctor write an appeal?" ... I would have laughed until I cried.  Not only weren't my local doctors interested in writing an appeal, they were dead set against me getting any treatment at all, saying ...

"You don't need any further treatment."
"There is this Dr. Sugarbaker.  However, if you went to  him, you would be disabled."
"There is no treatment for your disease.  And, if there were, they wouldn't pay for it."

Like I would trust any of these individuals to write an appeal for me.

I have learned much in the past three years.  When people find themselves in Insurance Denial-Land, their first reaction is to call the insurance company.  Once they figure out that they aren't getting anywhere with their insurance company by phone ... they call their doctor.

Once upon a time -- before the advent of Managed Care in the 1970s -- your doctor would have been the one to call when the insurer said "no."  Back then, your doctor's practice was an independent entity.  It was his job to find the best treatment for you, to request it of the insurance company, and to persuade them to pay for it.

Back in 1970, in their quest to control skyrocketing medical costs (How well has that worked?), the insurers came up with a brilliant concept.  Let's build a building, put all of the doctors in it, pay them a salary, and put a contract in place that says that the INSURER gets to decide what treatments get paid for.

Voila, the HMO is born.  PPO, POS -- whatever type of insurance you have, your doctor is probably contracted with the insurance company, and you live according to the principles of managed care.

There are two types of doctors that you will encounter:  Doctors who are contracted with your insurance company (in-network), and doctors who are not contracted with your insurance company (out-of-network).  Let's see what happens when each type of doctor writes your appeal.


In-network doctor writes appeal

He is bound by contract to your insurance company.  Therefore, it follows that he is not in the best position to mount a powerful appeal to make the insurer pay for something that they don't want to pay for.

Sort of like a quarterback going for a touchdown for the opposing team.


Out-of-network doctor writes appeal

The doctor who is not contracted with your insurance company (often your expert of choice) has no influence whatsoever on the insurer.

What repercussions are there if an out-of-network doctor asks for a treatment for you, and the insurer still says no?  None.


See where I am going with this?
The only person who has any traction with your insurance company is YOU.


Happy and peaceful Insurance Warrior-ing,

Laurie Todd