Transcript Slide 1

WORKING WITH
INSURANCE COMPANIES
TO OBTAIN COVERAGE FOR
APPROPRIATE TREATMENT FOR
EATING DISORDER CLIENTS
Lisa S. Kantor, Esq.
Kantor & Kantor
(877) 783-8686
www.KantorLaw.net
[email protected]
www.KantorLaw.net
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OUR ROADMAP
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Communication Fundamentals
The Intake
Preauthorization
Concurrent Review
Doc to Doc Review
The Appeal
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Communication Fundamentals
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Write down what you are going to say before any
telephone call
Write down everything that is said in the
conversation
Know the name, title, phone number and email
address of everyone you talk to
Send everything in – medical records, notes, letters
of support
Confirm everything in writing
Certified mail if possible
Have clients journal on insurance issues
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THE INTAKE
Confirming coverage
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Health Insurance
Two different types:
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Benefits obtained through an Employer (even if you
pay some or all of the premium) – covered by the
Employee Retirement Income Security Act (ERISA)
[Note: Does not apply to government or “church”
employees]
A policy purchased privately, through an insurance
agent.
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Employer Benefits – ERISA
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ERISA is a federal law that governs the insured’s rights
If a claim is denied, an appeal must be timely filed
before the insured can file a lawsuit
Insurers may be given great leeway
No jury trials
Federal judges make decisions if you have to file suit to
get your benefits
The judge will review the contents of the claim file and
very little else
Remedies are limited to benefits and attorneys fees
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Individual Insurance
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Typically no appeals required before a
lawsuit can be filed
Juries (not lifetime appointee judges)
make the decision on your case
Evidence outside of the file may be
considered by the jury
Remedies may include benefits, emotional
distress, attorneys fees and punitive
damages
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Important Differences Between ERISA
and Individual Coverage
ERISA Plans:
Individual Coverage:
No individual underwriting
Individually medically
underwritten
Cheaper – and your
employer may pay
More expensive and you pay
all the premium
Remedies restricted
Bad faith remedies available
in many states
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How did you get your coverage?
through my, or my
spouse’s, or my parent’s
employment
private purchase
Who is your employer?
Government,
religious entity
All others
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THE INSURANCE CARD IS NOT
ENOUGH…
What kind of coverage does this person have?
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INSURANCE BY ANY OTHER
NAME..
What is a Plan?
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What is a Policy?
Fiction created by ERISA
whenever an employer
offers health or welfare
benefits
May be funded by a
policy or by the employer
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Insurance to cover
certain risks or expenses
Not the same as
certificate or evidence of
coverage
May be the same as the
Policy or a different
document
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HOMEWORK FOR THE
CLIENT
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Send a letter to Human Resources to request
a copy of the Plan document
Send a letter to the Insurance Company to
request a copy of the Policy
Get copies or a CD of your medical records
Get letter(s) of support from treating
physicians, therapists, nutritionists, family,
co-workers, friends
Complete a HIPPA release
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CALL AND CONFIRM
COVERAGE
 Confirm,
don’t ask
 Write it all down
 Call back until you get the answer
you need
 Mail it in
 Remember the “fundamentals”
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PREAUTHORIZATION
Let the games begin . . . .
WHAT TO DO
BEFORE YOU CALL
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Gather information – patient homework
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CD of medical records
Plan and/or policy
Letters of support
Write to the claims administrator
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State what type of treatment the patient wants
Enclose the items above
Enclose/reference APA Guidelines
Ask for their guidelines
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WHAT TO KNOW
BEFORE YOU CALL
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“. . .ERISA imposes higher-than-marketplace
quality standards on insurers. It sets forth a special
standard of care upon a plan administrator, namely, that
the administrator “discharge [its] duties” in respect to
discretionary claims processing “solely in the
interests of the participants and beneficiaries” of
the plan, . . . it simultaneously underscores the
particular importance of accurate claims processing
by insisting that administrators “provide a ‘full and fair
review’ of claim denials.”
Metropolitan Life Ins. Co. v. Glenn, 128 S.Ct. 2343, 2350 (2008).
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The obligation to communicate . . .
“Under federal law, an ERISA plan “shall provide to every claimant
who is denied a claim for benefits written notice setting forth in a
manner calculated to be understood by the claimant:
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(1) The specific reason or reasons for the denial;
(2) Specific reference to pertinent plan provisions on which the
denial is based;
(3) A description of any additional material or information necessary
for the claimant to perfect the claim and an explanation of why such
material or information is necessary; and
(4) Appropriate information as to the steps to be taken if the
participant or beneficiary wishes to submit his or her claim for
review.” 29 C.F.R. § 2560.503-1(f).
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The obligation to communicate…
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In simple English, what this regulation calls for is a
meaningful dialogue between ERISA plan
administrators and their beneficiaries. If benefits are
denied in whole or in part, the reason for the denial
must be stated in reasonably clear language, with
specific reference to the plan provisions that form
the basis for the denial; if the plan administrators
believe that more information is needed to make a
reasoned decision, they must ask for it. There is nothing
extraordinary about this; it's how civilized people
communicate with each other regarding important
matters.” Booton v. Lockheed Medical Benefit Plan, 110 F.3d 1461 (9 Cir. 1997).
th
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PREPARE FOR THE CALL
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Gather the information – medical records,
letters, staff analysis
Match the information to the specific
criterion listed by the APA
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Write down what you are going to say
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Take a deep breath and have confidence!
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HOW TO CONDUCT THE CALL
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“I am calling from ABC Treatment Center to obtain
preauthorization/authorization for your insured, Jane Smith,
to start treatment with us. I know that once you hear Jane’s
story, you will agree that she requires the treatment we can
offer.”
Confirm that your letter was received; offer to e-mail or fax
and wait for receipt
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Tie the discussion to the specific criteria identified by the APA
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Don’t start with weight or BMI
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Emphasize the criteria that support the level of care you seek
or a higher level of care
Use prior treatment
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NOW CLOSE THE DEAL . . .
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What is your name? How can I contact you? How would you
like us to send you information (mail or e-mail)? What
address?
Do you have any questions?
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Do you need any more information?
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NO
Is there anything I should know about your procedures?
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NO
Are there any policy provisions or exclusions that would affect
coverage?
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NO
NO
Will you authorize [seven] days?
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YES
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AND CONFIRM THE DEAL
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The same day, send a letter to the
plan/insurer confirming the entire
conversation
If the person you spoke with will not give
you her/his name or address, send it to
the address in the plan/policy
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Certified mail if you can
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See sample letter
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CONCURRENT REVIEW
Be prepared . . .
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DAILY PREPARATION
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Daily progress notes and all other facility
records, including journals, are submitted
Match the information to the specific
criterion listed by the APA
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Write down what you are going to say
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Do not simply copy what you said before
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Take a deep breath and have confidence!
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HOW TO CONDUCT
THE CALL
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“I am calling from ABC Treatment Center. As you know,
you authorized seven days for your insured, Jane Smith,
to start treatment with us. Jane is still quite ill, and
requires continued treatment. I am asking that you
authorize another seven days.”
Confirm that your information was received; offer to email or fax and wait for receipt
Tie the discussion to the specific criteria identified by the
APA
Don’t start with weight or BMI
Emphasize the criteria that support the level of care you
seek or a higher level of care
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NOW CLOSE THE DEAL . . .
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What is your name? How can I contact you? How would you
like us to send you information (mail or e-mail)? What
address?
Do you have any questions?
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Do you need any more information?
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NO
Is there anything I should know about your procedures?
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NO
Are there any policy provisions or exclusions that would affect
coverage?
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NO
NO
Will you authorize [seven] additional days?
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YES
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…AND CONFIRM THE DEAL
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The same day, send a letter to the
plan/insurer confirming the entire
conversation
If the person you spoke with will not give
you her/his name or address, send it to
the address in the plan/policy
Certified mail if you can
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…OR CONFIRM THE DENIAL
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The same day, send a letter to the
plan/insurer confirming the entire
conversation
If the person you spoke with will not give
you her/his name or address, send it to
the address in the plan/policy
Certified mail if you can
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DOC TO DOC REVIEW
Leveling the playing field . . .
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BEFORE THE
DOC TO DOC CALL
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Show the doctor your letters enclosing the
documents and summarizing the
conversations
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Highlight the issues in a single paragraph
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Have the doctor see the patient
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Discuss with the doctor before the call
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HOW TO CONDUCT
THE CALL
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Initiate and participate in the phone call with the doctors
“I am calling from ABC Treatment Center. As you know, you denied
additional treatment for your insured, Jane Smith. Jane is still quite
ill, and requires continued treatment. We/you requested a doctor to
doctor conversation, and I am on the phone with Dr. Jones. Before
s/he speaks to you, I want to confirm that you have the entire file
in front of you, including the letters we submitted on [dates]. “
If s/he does not have the file, offer to e-mail or fax and wait for
receipt; if s/he does not want to wait, confirm that in writing after
the call
Focus on the points of contention
Emphasize the criteria that support the level of care you seek or a
higher level of care
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CONFIRM IN WRITING
CONFIRM IN WRITING
CONFIRM IN WRITING
CONFIRM IN WRITING
CONFIRM IN WRITING
CONFIRM IN WRITING
CONFIRM IN WRITING
CONFIRM IN WRITING
CONFIRM IN WRITING
CONFIRM IN WRITING
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THE APPEAL
Now we are really having some fun
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THE LAW OF ERISA APPEALS
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There are two critical things to know
about ERISA appeals
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The insured is entitled to a copy of the claim file –
sometimes called the administrative record – before
the appeal is decided
The insurer or plan may be entitled to discretion in
deciding the appeal
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WHAT IS THE CLAIM FILE AND
HOW DO I GET IT?
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The claim file consists of any document, record or other
information that was relied upon in making the benefit
decision, was submitted, considered or generated in the
course of making the benefit decision, or is a statement
of policy or guidance with respect to the plan concerning
the denied treatment (29 C.F.R. Section 2560.5031(m)(8))
The insured is entitled, upon request and free of charge,
a copy of the claim file (29 C.F.R. Section 2560.5031(h)(2)(iii))
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HOMEWORK FOR
THE PATIENT
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Send a letter to the Insurance Company of
Plan to appeal the denial and request a copy
of the claim file
Get letters of support from family and/or
friends
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PLAN DISCRETION:
THE FOX GUARDING THE HEN HOUSE
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Many plans/policies provide that the entity deciding whether
to pay claims has the “discretionary authority” to construe
and interpret the Plan and determine eligibility for benefits
This means that the court will give deference to the decision
of the Plan or insurer – the decision DOES NOT HAVE TO BE
RIGHT, IT ONLY HAS TO BE REASONABLE
BUT when the same entity is deciding whether to pay claims,
and is paying approved claims, the Supreme Court says there
is an “inherent” or “structural” conflict (Metropolitan Life Ins. Co. v.
Glenn, 128 S.Ct. 2343 (2008))
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The fox guarding the hen house (continued)
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A "structural" conflict of interest introduces an element of
skepticism into what would otherwise be deferential judicial
review.
The degree of skepticism depends on the extent of the
conflict. The types of evidence tending to show the influence
of a conflict include:
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inconsistent or insufficient reasons for the denial
determining a material fact without supporting evidence
failing to follow plan procedures
failing to provide a full and fair review of the denial
acting as an adversary bent on denying the claim
The more evidence of conflict, the less deference afforded to
the administrator, and the more "skeptical" the review
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WRITING THE APPEAL
LETTER
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This letter is submitted in support of Jennifer’s appeal of the
denial of continued residential treatment beyond March 8, 2009.
We will explain the history of Jennifer’s disease and treatment.
We trust that, after reading this letter, which carefully
documents Jennifer’s need for continued residential treatment,
you will approve Jennifer’s request to continue that treatment.
Summarize the prior letters and documents
Point out the inconsistencies
Point out the irregularities
Point out the omissions
Enclose any new documents
Conclude with specific requests
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YOU’VE GOT A FRIEND . . .
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Hopefully during this conference, you’ve
had the opportunity to connect with other
people in the industry…share ideas and
everybody will benefit
If you find yourself in a jam which you
think requires legal attention, find a
lawyer who specializes in this area, or feel
free to contact me.
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IADP RESOURCES:
www.KantorLaw.net/IAEDP_Resources
Lisa S. Kantor, Esq.
Kantor & Kantor
(877) 783-8686
www.KantorLaw.net
[email protected]
WORKING WITH
INSURANCE COMPANIES
TO OBTAIN COVERAGE FOR
APPROPRIATE TREATMENT FOR
EATING DISORDER CLIENTS
Lisa S. Kantor, Esq.
Kantor & Kantor
(877) 783-8686
www.KantorLaw.net
[email protected]