The Insurance Intelligencer 1/30/12
A tale of three Lauries
I would never have met the first Laurie, if my mother had not been dying.
In November, I was sitting at my computer in Seattle — making reservations to fly to Boston the next day. My mother was in her last days, and I needed to be at her side. I clicked over to my email. There was a message from a woman named Ena: “My cousin has been diagnosed with appendix cancer, she needs to get to Dr. Sugarbaker, her insurer has denied it. Can you help?”
I took a break from packing my suitcase, and called Ena. I asked, “What is your cousin’s name?” Ena replied, “Her name is Laurie.” Then I asked, “Where are you?” The family lives three miles from my sister’s house in Boston. I said, “You are not going to believe this, but I am going to be there tomorrow. I will meet with you if I can.”
This was just the beginning. If you look in the dictionary under “serendipity,” you will see a picture of this case.
A fateful meeting
A few days later, Laurie and her cousins Ena and Maria picked me up at my sister’s house. We proceeded to a local eatery.
Laurie was young, in her thirties. The cancer had been found during fertility treatments. This had all happened within a few weeks; they already had a surgery date booked with Dr. Sugarbaker. I asked, “How did you find Dr. Sugarbaker so fast?”
Dr. Paul Sugarbaker is a renowned gastrointestinal cancer surgeon in Washington, D.C. Many may not know that Dr. Sugarbaker’s younger brother Dr. David Sugarbaker is a renowned thoracic cancer surgeon at Brigham and Womens Hospital in Boston.
Ena replied, “I work as an operating room nurse for Dr. David Sugarbaker.”
The cousins asked questions, we talked, we got to know each other. At a certain point, Laurie started to cry. I put my arms around her and said, “I am going to help you. You are going to be alright.”
Little did we know what stormy seas we would face, before I could steer us safely to shore.
When Pilgrims attack
Laurie’s surgery date was 2/1/12. I would start writing her appeal in late January, and launch my pre-emptive strike on Harvard Pilgrim Health Care on 1/23/12.
I had never come up against Harvard Pilgrim before. From the moment my 51-page document landed on the Pilgrims’ doorstep … Laurie, the cousins and I were dragged face-first into a perfect storm. The full bureaucratic might of Harvard Pilgrim came crashing down on our heads. They threw everything at us in order to delay, deny, and stop us in our tracks.
We had five days — Monday through Friday — to persuade Harvard Pilgrim to approve this treatment. Surgery date was the following Wednesday.
As of Wednesday afternoon, Harvard Pilgrim denied the surgery a second time, and sent the case to the Patient Protection Office (OPP) for independent review. Harvard Pilgrim refused to give us a copy of the denial letter, saying, “We can’t give it to you, wait for our letter, etc.”
Laurie and her cousins put the full-court press on Harvard Pilgrim to get the denial letter to me. On Thursday morning, the second denial came rolling off my fax machine. It was another sham review, with a hired-gun “expert,” and a few specious arguments. I would have to write a second letter, to refute all of this foolishness.
Attached to the denial letter was an 8-page application form to request the independent review. There were several pages that needed to be signed by Laurie, and a three-page request for expedited revew that need to be filled out and signed by her doctor. Along with the applications, we needed to include her entire medical record, a copy of her insurance card, a complete copy of Harvard Pilgrim’s denial, and a $25 fee. It was now noon on Thursday.
I composed my blistering second letter. Six thousand phone calls, emails and faxes flew between Laurie, cousin Maria, Dr. Sugarbaker’s office, Laurie’s local physicians’ offices, and me.
I put together my blistering letter, the 11-pages of applications, the medical record, the denial, and my original 51-page appeal document — and faxed it all to the OPP office. Meanwhile, cousin Maria was racing to the OPP office in Boston — to deliver the $25 fee. It was now late Thursday afternoon.
The Helpful Insider
This is where the Compassionate Buddhas finally decide to send us some help: the Helpful Insider. Maria takes full advantage of this precious gift.
Maria runs into the OPP office with her $25, and meets the person who puts the packages together. This person then delivers the packages to three independent review organizations. The three orgs then vote, and majority rules. She explains to Maria that the review orgs will decide Laurie’s fate by next Wednesday.
Maria says, “That won’t work for us.” She goes on to explain what-all we have been through over the past months and days. The OPP person starts to get a little teary-eyed. When I hear this part, I know that the clouds have parted, and a tiny ray of sunshine is shining down on us.
Very important people
Laurie and her cousins come from a large and loving family. It seems that everyone they know works for the Commonwealth of Massachusetts, is an attorney, or knows some important political figure. They were all poised to do something.
On Thursday evening, I had done all that I could do. I said, “Have all of your important people have a word with Dr. Bigby, Commissioner Murphy, and the president/CEO of Harvard Pilgrim. Tell them that we need a decision no later than Friday — next week will not do.”
At this point, everyone was asking, “What do we do if they deny it again, we have eight family members with plane reservations, etc.”
I said, “We are on the freeway. I am behind the wheel, I am driving. We have to keep our eyes on the road, and just keep driving.”
Laurie #2
So, where does the third Laurie come in?
On Tuesday afternoon — in the midst of the firestorm with Boston Laurie — I received a call from Laurie #2 in Virginia. This Laurie is a physician, she needed to get to Dr. Sugarbaker, and Anthem BC/BS of Virginia had denied it.
Dr. Laurie’s surgery date was Tuesday, 1/31 — one day before Boston Laurie.
In order to make the second case work, I would have to stay up all night on Tuesday, craft an appeal, and email and fax the appeal Wednesday morning.
I couldn’t let Anthem BC/BS of Virginia get away with this, as I had won an appeal against them for this treatment three months ago.
Two glorious victories
On Thursday afternoon, Dr. Sugarbaker’s office called. We had approval for Dr. Laurie in Virginia — victory in one day.
On Friday at 11:00 a.m., Laurie from Boston called. Her treatment was approved.
Dr. Laurie has her surgery on Tuesday. Boston Laurie has her surgery on Wednesday. How I would love to be there when they meet.
World, meet Laurie from Boston
If you like this story, forward it on. Everyone who has health insurance needs to read it.
Peaceful Insurance Warrior-ing,
Laurie Todd
http://www.theinsurancewarrior.com/
