DENIED . . . NOW WHAT?

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

Everything

Ridiculous

Imagined

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 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?

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