denied . . . now what?
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DENIED . . . NOW WHAT?
By
Eric H. Weitz, Esquire
Seidel Weitz Garfinkle & Datz, LLCTraditional Values Modern Approach
The Diagnosis
Good News – Bad News
The Prescription
Elemental Formula
Trial period to permanent.
Oral if possible.
Few options.
$$$$$$$
The ClaimClinical Notes
Comprehensive Medical History
Claim Forms
Letter of Medical Necessity
Proper Coding
Correct Office
Time Limitations
Submit to PBM
Submit to Case Management
Etc. Etc. Etc. Etc.
The Decision
Now What?
“ Perhaps it is good to have a beautiful mind, but an even greater gift is to discover a beautiful heart.”
Russell Crowe as
John Forbes Nash in
A Beautiful Mind, 2001
The Game Theory
The Game Theory is the study of strategic situations where players choose different actions in an attempt to maximize their returns.
Rules of the Game
ERISA
Everything
Ridiculous
Imagined
Since
Adam
Rules of the Game (cont.)
ERISA - Good intentions gone awry
Employee Retirement Income Security Act of 1974
ERISA – What you need to know
1. Presume that you lose!2. The Plan documents.3. Standard of review is
arbitrary and capricious unless an exception applies.
4. The administrative appeal.
5. Going to court.
Get the Documents
From Employer
From Employer
From Employer and Carrier
From Carrier
Plan Document
Summary Plan Description
Insurance Policy
All Documents relied upon in deciding your claim
Get the Research
Peer reviewed journal articles.
Articles authored by the carrier’s own physicians.
Get past medical bills and explanations of benefits.
Get a Specific Medical Opinion
Parrot language from Plan, Summary Plan Description and Policy!!!!
Have physician rely on, among other things, unique clinical findings, experience, journal articles.
“Within a reasonable degree of medical certainty.”
Get Creative
Videos and Photographs
Interviews
News articles and reports
Statements from government agencies
The Administrative Appeal
• Significance of the record - everything MUST be in writing.
• Timing
• Fill the record with facts, data and medical opinions.
• Always offer to respond to any questions that they have or if they think there is insufficient information!!!
Meeting the Claims Committee
Meeting the Claims CommitteeBring a witness to take notes.
Think twice before bringing patient.
Stay calm and be yourself.
Identify applicable policy and/or Plan language.
Identify weakness of their opinion.
Offer to supplement record if new questions are raised.
Offer to provide additional information if they believe they do not have sufficient information.
Last Step
What Can We Do?
Lobby
1. State Mandates.
2. Insurance Commissioner adoption of model language regarding delegating discretion.
3. Enlist greater participation by manufacturers.
What Can We Do?
Educate1. Medical directors at insurance carriers (cost-benefit analysis)
2. Employers (cost-benefit analysis)
3. Healthcare staff members (how to document charts and write letters of medical necessity)
What Can We Do?
“ Perhaps it is good to have a beautiful mind, but an even greater gift is to
discover a beautiful heart.”
Russell Crowe as
John Forbes Nash in
A Beautiful Mind, 2001
Advocate
Don’t lose heart!
DENIED . . . NOW WHAT?
By
Eric H. Weitz, Esquire
Seidel Weitz Garfinkle & Datz, LLCTraditional Values Modern Approach
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