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DENIED . . . NOW WHAT?. By Eric H. Weitz, Esquire. Seidel Weitz Garfinkle & Datz, LLC Traditional Values Modern Approach. The Diagnosis. Good News – Bad News. The Prescription. Elemental Formula. Trial period to permanent. Oral if possible.

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DENIED . . . NOW WHAT?

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Denied now what

DENIED . . . NOW WHAT?

By

Eric H. Weitz, Esquire

Seidel Weitz Garfinkle & Datz, LLC

Traditional Values Modern Approach


The diagnosis

The Diagnosis

Good News – Bad News


The prescription

The Prescription

Elemental Formula

Trial period to permanent.

Oral if possible.

Few options.

$$$$$$$


The claim

The Claim

Clinical 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

The Decision


Now what

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

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

Rules of the Game

ERISA

Everything

Ridiculous

Imagined

Since

Adam


Rules of the game cont

Rules of the Game (cont.)

ERISA - Good intentions gone awry

Employee Retirement Income Security Act of 1974


Erisa what you need to know

ERISA – What you need to know

  • Presume that you lose!

  • The Plan documents.

  • Standard of review is arbitrary and capricious unless an exception applies.

  • The administrative appeal.

  • Going to court.


Get the documents

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

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

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

Get Creative

Videos and Photographs

Interviews

News articles and reports

Statements from government agencies


The administrative appeal

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 Committee


Meeting the claims committee1

Meeting the Claims Committee

Bring 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

Last Step


What can we do

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 do1

What Can We Do?

Educate

1.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 do2

What Can We Do?

Advocate

Don’t lose heart!

“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


Denied now what1

DENIED . . . NOW WHAT?

By

Eric H. Weitz, Esquire

Seidel Weitz Garfinkle & Datz, LLC

Traditional Values Modern Approach


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