Need to Win An Insurance Company Appeal? Here's How It's Done.

Adam Berkowitz and his team had only two days to convince a young mom’s insurance company to pay for the care she needed to keep fighting cancer. 

​The young woman – a friend of Adam’s wife – had suffered a recurrence of her pancreatic cancer. A tumor had spread to her liver and her doctors at MD Anderson said it had to be treated right away. But the woman’s insurance company was denying the radiofrequency ablation procedure her doctors recommended to destroy the cancer cells. The insurer claimed it wasn’t “medically necessary,” a common excuse health insurance companies use to deny care. 

The young mom had lost her appeals and didn’t know what to do. It was a Thursday in September and she had to fly to MD Anderson on Sunday. If the insurance company wouldn’t approve the procedure, she would need to pay the $47,900 price tag, up front, to get the procedure she needed to save her life. 

​Insurance company denials are common. Americans pay more than ever for health insurance deductibles and premiums. But the companies routinely block the coverage they need. It’s hard to overstate the emotional toll these insurance company battles take on patients. I talked to the young mom who Adam and his team helped. She didn’t want her name or other identifying information used in this write up for privacy reasons. She said it felt so stressful to have to fight the appeal as a mom who also had to fight cancer that was spreading in her body.

I showed how to win an insurance company appeal in my book, "Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win." I featured the tactics of Laurie Todd, an advocate known as The Insurance Warrior. Here’s how you win. You fight the insurer with evidence, pointing to its contractual requirement to provide the care. And you layer on heavy doses of urgency and social pressure. 

Adam runs a St. Louis health benefits company called Simpara. He’s read my book. In fact, he bought 200 of them for his clients and prospects! So my book served as a guide when he and his team jumped into the battle. He also referred to a copy of one of The Insurance Warrior’s appeals, which I have posted on my website as a resource. Adam is a benefits pro, but he said the book and the sample appeal were his roadmaps. 

​Adam said he was initially tempted to write an emotional appeal letter on behalf of the young mom. He’s a husband and a father of three. He could relate to this young mom, a wife, an employee, who had been dealt an awful hand. “Why was the insurance company putting her through this type of stress when this is what all her doctors were recommending?” he asked himself.

​It’s an understandable instinct, and emotion should be a key component in any appeal. But a common mistake is to make an appeal ONLY about emotion. You win these appeals by arguing with evidence. You have to prove that the insurer is failing to abide by the terms of its contractual agreement by denying the patient the care she needs.

Adam and his team put together a brilliant 8-page appeal memo. They cited the credentials of the surgeon. And they showed the evidence that backs the validity of the less invasive ablation procedure the doctor recommended. The insurance company’s denial claimed the procedure was not “medically necessary.” So they referred to the health plan’s Summary Plan Document – its contractual agreement to provide coverage – to define “medical necessity.” Medically necessary procedures, the document said, are those that are required and the most economical available. The ablation fit those criteria. 

​Further, they cited page 42 of the Plan Document, which said the decisions about treatment were “entirely between you and your Physician.” Piling on even more, they cited the insurer’s own medical policy, which said the radiofrequency ablation procedure is associated with lower complications, less blood loss and a shorter length of stay. Their appeal document also cited a second medical opinion that validated the safety and necessity of the procedure. In conclusion, they summarized that “it is our full expectation that the additional documentation provided satisfies Medical Necessity.”

​Adam and his team also created a sense of URGENCY around the appeal. They titled it as the Insurance Warrior recommends: URGENT EXPEDITED REQUEST FOR RECONSIDERATION. Yes, it’s ALL CAPS. BOLD. And UNDERLINED. Gotta get their attention. ​

And then Adam applied social pressure, which is the secret sauce for success. By Thursday morning they faxed the appeal to the insurance company, and then Adam and his team started calling everyone they could find who worked for the insurer. They also called the young mom’s employer, a global food and beverage packaging company. 

About 155 million Americans get their benefits through their employer. In those cases, you MUST involve your employer in any urgent appeal. In many cases, particularly with larger employers, they are running a self-funded health plan. That means the employer is ultimately on the hook for the medical costs and hires an insurance company to operate as a third-party administrator, paying the claims. In those cases, the employer sets the policies, not the plan administrator. So the employer needs to be urged to approve the care the patient needs. ​

Adam’s team faxed the appeal document to every number they could find in the plan documents. They were told that the fastest an urgent appeal could be turned around was 72 hours, but they didn’t have that much time. He worked the phones, calling every number he could find at the insurance company, and everyone he could think of at her employer, including the executives. He left the emotion out of it and kept the message simple: “We have a client seeking an expedited appeal. She needs to fly out in two days.” 

​Adam’s breakthrough came via the insurer’s peer-to-peer phone line. That’s where the physicians for the insurer talk to the doctors treating their members. It was the only place he could get a real person to respond to him who had insight into the process. Within hours of blitzing everyone he could think of with phone calls, while he was talking to the peer-to-peer representative, Adam got the great news: The procedure had been APPROVED IN FULL. 

​He doesn’t know how the approval happened, but he was overcome by a flood of relief. “I wanted to jump through the phone and kiss this woman,” he said. “In all my career I’ve never seen anything like this. We were all in tears.”

The young mom got the procedure she needed and is now recovering. Her latest bloodwork, pending a scan to confirm the prognosis, shows no evidence of the cancer. If the scans show she remains clear, she told me, her treatment will be complete.  

Would you like to help EQUIP and EMPOWER patients to stand up for themselves against the predatory practices of the health care system? Please support my Indiegogo crowdfunding campaign to turn my book into a series of health literacy videos. And please keep up with my newsletter to stay tuned on the latest in this movement to protect health care consumers.