DENIED . . . NOW WHAT?

1. DENIED . . . NOW WHAT? By Eric H. Weitz, Esquire Seidel Weitz Garfinkle & Datz, LLC Traditional Values Modern Approach

2. The Diagnosis Good News – Bad News

3. The Prescription Elemental Formula Trial period to permanent. Oral if possible. Few options. $$$$$$$

4. 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.

5. The Decision

6. 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

7. The Game Theory The Game Theory is the study of strategic situations where players choose different actions in an attempt to maximize their returns.

8. Rules of the Game ERISA Everything Ridiculous Imagined Since Adam

9. Rules of the Game (cont.) ERISA - Good intentions gone awry Employee Retirement Income Security Act of 1974

10. 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.

11. 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

12. Get the Research Peer reviewed journal articles. Articles authored by the carrier’s own physicians. Get past medical bills and explanations of benefits.

13. 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.”

14. Get Creative Videos and Photographs Interviews News articles and reports Statements from government agencies

15. 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!!!

16. Meeting the Claims Committee

17. 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.

18. Last Step

19. What Can We Do? Lobby 1. State Mandates. 2. Insurance Commissioner adoption of model language regarding delegating discretion. 3. Enlist greater participation by manufacturers.

20. 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)

21. 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

22. DENIED . . . NOW WHAT? By Eric H. Weitz, Esquire Seidel Weitz Garfinkle & Datz, LLC Traditional Values Modern Approach