January 24, 2013
I am grateful to have insurance. I am grateful to have insurance. I am grateful to have insurance...I truly am grateful for insurance as well as my newfound complete insurance education.
My insurance provider switched at the start of 2013. This was a move that made complete business sense for my employer. It sounded like it would have no effect on me as my team of doctors at the University of Colorado showed as covered in-network doctors under the new insurer. In addition the new insurance company had a transition plan for all people currently receiving specialized treatment. Piece of cake, right?
Turns out the new insurance company has a system that is a bit misleading about what is covered as in-network doctors verse affiliate providers that are not covered unless there is a referral from an in-network doc to see the out of network doc. But then there is the application for transition of care that should cover it, right? Maybe…this is only if the new insurance company deems it necessary or cannot provide, in their eyes, the same services. Who cares if you have built relationships with your current providers or trust them or they have a research background and a team of people all at the same location? Does it matter that you have a team of specialists that treat ONLY breast cancer and ONLY women under the age of 45? Does that matter? Does it matter that you have had one set of doctors start a reconstruction surgery on your chest and it is ludicrous to have another set of new doctors finish what the others started? The new insurers doc even agrees they should not jump in the middle but apparently corporate execs are medically smarter than the docs they contract with.
Needless to say my application for continuity of coverage to finish my chemotherapy and reconstruction surgery at the University of Colorado was denied because the new insurance company has doctors that can provide those "same" services.
I now know more about insurance than I ever thought I would. I have also learned that you HAVE to be your own health advocate because nobody cares as much as you and your family do. If there is anything I can encourage others to do, be your own advocate.
The new insurance company didn’t think it was important that I had done all of my chemo teaching at the University of Colorado or that the University of Colorado is known as one of the top 40 cancer centers in the US. The new insurance company also didn’t think it was important that I had done ½ or more of my reconstructive surgery with the University of Colorado doctors. The new insurance company's doctors can provide a "standard of care" to finish those surgeries. I am not going for a "standard of care"...this is my body as well as my physical and emotional health. I want the best of the best. In addition, going to a new team of doctors to finish a surgery already started is like having one artist start a sculpture and another artist finish. Yes, I did just equate my new boobs to an artist’s sculpture…you better believe it!
I had a lot of arguments but it was crucial to get them all out of my head, down on paper and organized so they would make sense to others. I have a good friend who is a lawyer in Wyoming and she kindly offered to help me put together my appeal. She spent a good couple of hours…that’s over $900 of billable time…helping me organize and enhance my arguments with external sources such as data from the American Cancer Society, a press release from the insurer saying even they are partnering with the University of Colorado because of the University of Colorado's top ranking in cancer research...and additional information directly off the insurance company's website. In addition she encouraged me to write my appeal from my heart and NOT to leave out the emotional appeal - what I was feeling and experiencing due to this process.
It is important to use any and all of your available resources. I had my lawyer friend as well as notes from four different doctors writing about how important it was for my health (physical, emotional, mental) to stay with the doctors at the University of Colorado - notes came from my both my doctors at the University of Colorado as well as external doctors. My cousin works in the insurance industry and has been a God send in getting information to the top level of the insurance company and had the ear of an executive. I saw an oncologist at this new insurer and she issued a referral for my surgery to remain at the University of Colorado. I connected with the insurance brokers (through my employer) who many times have pull with the insurance company. In addition I connected with the HR group at my employer and their contact at the insurance company. It was crucial that I had as many people working on my behalf as possible.
It addition it is extremely important to read the documents about the appeal process from your insurer. I read through them as well as my lawyer friend…she highlighted a couple of sections for me to follow-up with. This is important to read yourself AND have someone else read through the pages of details to be sure you don’t miss anything. Trust me…many people do not read the documents and they don’t know all the possible options available.
To give you a sense of how important it is to read the documentation from the insurance company, I checked with the Colorado Department of Insurance (yes it exists and I had no idea until this process either) about the number of people that had filed appeals. In 2011 for my specific insurance company 70+ second appeals had been filed. Only 12 of those requested an external review. An external review cost me no additional money and all the work is done by the Department of Insurance from your state - I would not have known about the external review process and option had I not read the multiple pages sent by my insurer about my "legal" rights.
So I filed my appeal AND asked for an external review to be conducted at the same time. What does this mean? It means that someone OUTSIDE the insurance company (an independent 3rd party with expertise in the medical area in the case) reviews your file and actually has the final say. The insurance company is legally bound to uphold this decision. So I requested an external appeal at the same time. In order to get this expedited…72 hours instead of 30 days requires another note from your doctors explaining the need for this to be a quick decision. It is a laborious process, but don’t give up. For me I had to know I had done everything I possibly could even if the answer was still a “no”. Trust me, there were many times I was hopeless, felt like I had been reduced to a number, forgotten by God…but the whole time He was there carrying me.
Here is the process required by law for an external appeal:
· The Department of Insurance assigns the external review to a outside company. Colorado Department of Insurance happens to have 12 different external review organizations that they rotate assignment through - call your department of insurance to find out more about your state's process. Ask questions.
· You have a small window of time to object if you have a conflict of interest with the external review organization selected - they then switch the external reviewer chosen
· You then have a small window of time to submit additional documentation for your case - I did submit two additional documents and that gave me a chance to talk with the director of the external review organization and put a voice with a name
· The external review company assigns your case to a specialist in the field and they render a review and decision of your case - they cannot have been involved earlier and cannot have ties to your insurance company. This is the key...they have NO financial ties to your insurer.
· You can request the "case" paperwork to be sent to you. The same thing your insurance company sent to the external reviewer - make this request to see your case paperwork. It is always good to know what was sent and be sure your components were sent
· The external reviewer submits the decision and the insurance company is legally bound to follow that decision
In my case, after two internal denials of my request, the external reviewer found in my favor. They OVERTURNED both of my insurance company's prior decisions and said it was "merciless" to add any more weight to my shoulders by requiring me to change my doctors at this time in my life. I have no doubt that God hand picked the reviewer in my case and gave me the ability, through myself and others, to write an appeal that truly represented my case as if I was there in person. My CPA who also reviewed all of the documents referred to the new insurer as the “Corporate Bully”.
This is HUGE, HUGE, HUGE for me and was the product of pulling together my resources, my knowledge, exploring all possible solutions and prayer. I encourage you, if you have a case and you believe you should be heard, follow your heart and follow through doing everything possible to be heard. Do not back down. Fight for yourself. Approaching it this way, at the end of the day you know you have done everything possible regardless of the final answer.
I had a hard time getting the University of Colorado to believe that I had gotten approval to stay with them...until we had all of the approval codes in the system and they had talked directly to my new insurance company. They said this has NEVER happened...my doctor said in 10+ years this insurance company has never allowed a patient to stay at their current provider to finish treatment. It was a tireless process but one with an outcome that I feel blessed beyond belief and thankful for all those praying for this resolution.
If you have questions or need help with insurance as you go through any health process, please feel free to reach out to us.
Jeydrienne
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