At 10.39 on Wednesday February 19th Health Partners called me to tell me that based on the information contained in my appeal they had decided to APPROVE my amputation in Boston! My new surgery date is May 22nd. This is the result of a multilayered miracle that played out over the past three weeks.
It only took a couple days of phone calls and online searches for me to discover I could not change my health insurance. November is enrollment time and unless I got dropped by my insurance I couldn’t shop around for a better policy ie one that would cover me where I need to be treated. This meant that I needed to go through the appeals process.
I had already written an appeal last year when upon discovering that my wound was now hosting a form of skin cancer (squamous cell carcinoma) my local Doctor said he needed to amputate me above knee (AK). This prompted our finding Dr Carty in Boston. He is one of the top reconstructive surgeons in the world and he had designed a treatment plan that would save my knee by giving me a modified below knee (BK). My insurance refused to pay for it and I appealed. Their letter explained the reason for denial was I could get the same treatment in network! Obviously that was the opposite of true, and I would have taken the appeal to the state except that by this time the cancer had progressed to the point that even Dr Carty was unable to save the knee. I was then accepted into the Ewing amputation Clinical Trial for an AK, which is what my insurance most recently refused to pay for.
Just when I thought I would have to face the insurance company and their twisted logic alone again my Mum forwarded me a link to a lady who called herself the insurance warrior. The link had been sent to her by my brother Joel who had shared my story with a guy named Pat who he was working with the day my surgery was cancelled. Pat said his wife Barbara had fought her insurance and won years ago. She had been helped by a book she read written by a lady named Laurie Todd. I clicked on the link and watched Laurie tell the story of how she became the insurance warrior. After being denied coverage for her own life saving cancer treatment, she appealed and won her case, and has been winning cases (218) with other patients for the last 15 years. Of the 9 billion people on the planet I knew this was the one person who could help me. I sent her an email before I even finished watching her talk.
The next morning she had emailed back. She had found me on facebook, made sure I was a real person, gave me some homework and said we would talk the next day. I did my homework and continued to do so and a couple days and many phone calls later she agreed to take my case. We spent the next week constructing an appeal that not only told my story, but explained legally and medically why they had to cover my surgery. We showed they had already damaged my health by denying the BK operation last year and that the Ewing is not the same as a conventional amputation, that my long term health will benefit from it and it is obviously not available in network. Laurie also discovered in my own member benefits book that their own language forced them to cover clinical trials if they were backed by the Department of Defense, which my trial is. Laurie has a masters in psychology and french literature, two genres of expertise that coalesce beautifully to make her the perfect person to craft a story and an appeal that gets immediate and right action from those to whom it was written. As she said during a phone call last week “we never know what we are in training for”!
One of my homework assignments was to track down the other patients who have already experienced the Ewing amputation. We needed to show precedent, that this is a surgery other insurers are paying for, and the results are as good as the literature suggests. This was another unexpected blessing of working on the appeal. Many of the cohort reached out to me and talked with me on the phone including Jim Ewing the 1st to have the surgery and it’s namesake. All the folks who reached out to me and shared their information were helpful, positive and very excited for me to join their exclusive and life changing club. Showing precedent was easy to do.
The insurance warrior doesn’t mess around, She doesn’t just know how to write an appeal she knows how to put it out there so it will make the most impact. I won’t give away too many of her secrets (although she gives them away in her book) but we sent the appeal to all the top brass at Health Partners and the top folks in oversight at the government in DC and here in MN. Laurie tracks down as many personal numbers and emails for all these folks and the day after the appeal went out I hit the phones. I called and followed her script as I created an extra sense of urgency in the offices of these people who don’t normally ever see appeals because they have a system already set up to turn them down. As Laurie says if you want to beat the insurance company do the opposite of what they tell you to do.
That’s just what we did. When the president of Health Partners’ receptionist told me someone else is handling it so we don’t need to call this office anymore I said thank you and called them back at the end of the day just to check any way. It didn’t take long though. The appeals went out Sunday evening and we had our yes by Wednesday morning. Turns out the peace I experienced after the “bad” news in Boston three weeks ago was completely justified. I had an adventure with a divinely appointed angel. I got to take care of some practical life stuff that I wouldn’t have been able to deal with had the surgery happened when it was planned. I got to enjoy a little vacation in Boston with my parents who are two of the best people anywhere to hang out with and when I go back in May for the real deal I will be better prepared, in better health and with even more to be grateful for.