Lisa S. Kantor, Esq.Kantor & Kantor(877) 783-8686www.KantorLaw.netLKantor@KantorLaw.net

WORKING WITH INSURANCE COMPANIES TO OBTAIN COVERAGE FOR APPROPRIATE TREATMENT FOR EATING DISORDER CLIENTS

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OUR ROADMAPCommunication FundamentalsThe IntakePreauthorizationConcurrent ReviewDoc to Doc ReviewThe Appeal

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Communication FundamentalsWrite down what you are going to say before any telephone callWrite down everything that is said in the conversationKnow the name, title, phone number and email address of everyone you talk toSend everything in medical records, notes, letters of supportConfirm everything in writingCertified mail if possibleHave clients journal on insurance issues*www.KantorLaw.net

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THE INTAKEConfirming coverage*www.KantorLaw.net

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Health InsuranceTwo different types:

Benefits obtained through an Employer (even if you pay some or all of the premium) covered by the Employee Retirement Income Security Act (ERISA) [Note: Does not apply to government or church employees]

A policy purchased privately, through an insurance agent.

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Employer Benefits ERISAERISA is a federal law that governs the insureds rightsIf a claim is denied, an appeal must be timely filed before the insured can file a lawsuit Insurers may be given great leewayNo jury trialsFederal judges make decisions if you have to file suit to get your benefitsThe judge will review the contents of the claim file and very little elseRemedies are limited to benefits and attorneys feeswww.KantorLaw.net*

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Individual InsuranceTypically no appeals required before a lawsuit can be filedJuries (not lifetime appointee judges) make the decision on your caseEvidence outside of the file may be considered by the juryRemedies may include benefits, emotional distress, attorneys fees and punitive damageswww.KantorLaw.net*

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Important Differences Between ERISA and Individual CoverageERISA Plans:

No individual underwriting

Cheaper and your employer may pay

Remedies restrictedIndividual Coverage:

Individually medically underwritten

More expensive and you pay all the premium

Bad faith remedies available in many states www.KantorLaw.net*

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THE INSURANCE CARD IS NOT ENOUGH

What kind of coverage does this person have?*www.KantorLaw.net

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INSURANCE BY ANY OTHER NAME..What is a Plan?

Fiction created by ERISA whenever an employer offers health or welfare benefitsMay be funded by a policy or by the employerMay be the same as the Policy or a different documentWhat is a Policy?

Insurance to cover certain risks or expensesNot the same as certificate or evidence of coverage *www.KantorLaw.net

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HOMEWORK FOR THE CLIENTSend a letter to Human Resources to request a copy of the Plan document Send a letter to the Insurance Company to request a copy of the PolicyGet copies or a CD of your medical recordsGet letter(s) of support from treating physicians, therapists, nutritionists, family, co-workers, friendsComplete a HIPPA release

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CALL AND CONFIRM COVERAGEConfirm, dont askWrite it all downCall back until you get the answer you needMail it inRemember the fundamentals*www.KantorLaw.net

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Let the games begin . . . . PREAUTHORIZATION

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WHAT TO DO BEFORE YOU CALLGather information patient homeworkCD of medical recordsPlan and/or policyLetters of supportWrite to the claims administratorState what type of treatment the patient wantsEnclose the items aboveEnclose/reference APA GuidelinesAsk for their guidelines

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WHAT TO KNOW BEFORE YOU CALL. . .ERISA imposes higher-than-marketplace quality standards on insurers. It sets forth a special standard of care upon a plan administrator, namely, that the administrator discharge [its] duties in respect to discretionary claims processing solely in the interests of the participants and beneficiaries of the plan, . . . it simultaneously underscores the particular importance of accurate claims processing by insisting that administrators provide a full and fair review of claim denials. Metropolitan Life Ins. Co. v. Glenn, 128 S.Ct. 2343, 2350 (2008). *www.KantorLaw.net

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The obligation to communicate . . .Under federal law, an ERISA plan shall provide to every claimant who is denied a claim for benefits written notice setting forth in a manner calculated to be understood by the claimant: (1) The specific reason or reasons for the denial; (2) Specific reference to pertinent plan provisions on which the denial is based; (3) A description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary; and (4) Appropriate information as to the steps to be taken if the participant or beneficiary wishes to submit his or her claim for review. 29 C.F.R. 2560.503-1(f). *www.KantorLaw.net

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The obligation to communicateIn simple English, what this regulation calls for is a meaningful dialogue between ERISA plan administrators and their beneficiaries. If benefits are denied in whole or in part, the reason for the denial must be stated in reasonably clear language, with specific reference to the plan provisions that form the basis for the denial; if the plan administrators believe that more information is needed to make a reasoned decision, they must ask for it. There is nothing extraordinary about this; it's how civilized people communicate with each other regarding important matters. Booton v. Lockheed Medical Benefit Plan, 110 F.3d 1461 (9th Cir. 1997).

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PREPARE FOR THE CALLGather the information medical records, letters, staff analysisMatch the information to the specific criterion listed by the APAWrite down what you are going to sayTake a deep breath and have confidence! *www.KantorLaw.net

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HOW TO CONDUCT THE CALLI am calling from ABC Treatment Center to obtain preauthorization/authorization for your insured, Jane Smith, to start treatment with us. I know that once you hear Janes story, you will agree that she requires the treatment we can offer.Confirm that your letter was received; offer to e-mail or fax and wait for receiptTie the discussion to the specific criteria identified by the APADont start with weight or BMIEmphasize the criteria that support the level of care you seek or a higher level of careUse prior treatment *www.KantorLaw.net

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NOW CLOSE THE DEAL . . .What is your name? How can I contact you? How would you like us to send you information (mail or e-mail)? What address?Do you have any questions?NODo you need any more information?NOAre there any policy provisions or exclusions that would affect coverage?NOIs there anything I should know about your procedures? NOWill you authorize [seven] days?YES

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AND CONFIRM THE DEALThe same day, send a letter to the plan/insurer confirming the entire conversationIf the person you spoke with will not give you her/his name or address, send it to the address in the plan/policyCertified mail if you canSee sample letter *www.KantorLaw.net

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CONCURRENT REVIEWBe prepared . . .*www.KantorLaw.net

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DAILY PREPARATIONDaily progress notes and all other facility records, including journals, are submittedMatch the information to the specific criterion listed by the APAWrite down what you are going to sayDo not simply copy what you said beforeTake a deep breath and have confidence! *www.KantorLaw.net

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HOW TO CONDUCT THE CALLI am calling from ABC Treatment Center. As you know, you authorized seven days for your insured, Jane Smith, to start treatment with us. Jane is still quite ill, and requires continued treatment. I am asking that you authorize another seven days.Confirm that your information was received; offer to e-mail or fax and wait for receiptTie the discussion to the specific criteria identified by the APADont start with weight or BMIEmphasize the criteria that support the level of care you seek or a higher level of care

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NOW CLOSE THE DEAL . . .What is your name? How can I contact you? How would you like us to send you information (mail or e-mail)? What address?Do you have any questions?NODo you need any more information?NOAre there any policy provisions or exclusions that would affect coverage?NOIs there anything I should know about your procedures? NOWill you authorize [seven] additional days?YES

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AND CONFIRM THE DEALThe same day, send a letter to the plan/insurer confirming the entire conversationIf the person you spoke with will not give you her/his name or address, send it to the address in the plan/policyCertified mail if you can*www.KantorLaw.net

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OR CONFIRM THE DENIALThe same day, send a letter to the plan/insurer confirming the entire conversationIf the person you spoke with will not give you her/his name or address, send it to the address in the plan/policyCertified mail if you can*www.KantorLaw.net

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DOC TO DOC REVIEWLeveling the playing field . . .*www.KantorLaw.net

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BEFORE THE DOC TO DOC CALLShow the doctor your letters enclosing the documents and summarizing the conversationsHighlight the issues in a single paragraphHave the doctor see the patient Discuss with the doctor before the call

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HOW TO CONDUCT THE CALLInitiate and participate in the phone call with the doctorsI am calling from ABC Treatment Center. As you know, you denied additional treatment for your insured, Jane Smith. Jane is still quite ill, and requires continued treatment. We/you requested a doctor to doctor conversation, and I am on the phone with Dr. Jones. Before s/he speaks to you, I want to confirm that you have the entire file in front of you, including the letters we submitted on [dates]. If s/he does not have the file, offer to e-mail or fax and wait for receipt; if s/he does not want to wait, confirm that in writing after the callFocus on the points of contention Emphasize the criteria that support the level of care you seek or a higher level of care

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CONFIRM IN WRITING

CONFIRM IN WRITING

CONFIRM IN WRITING

CONFIRM IN WRITING

CONFIRM IN WRITING

CONFIRM IN WRITING

CONFIRM IN WRITING

CONFIRM IN WRITING

CONFIRM IN WRITING

CONFIRM IN WRITING

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THE APPEALNow we are really having some fun *www.KantorLaw.net

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THE LAW OF ERISA APPEALSThere are two critical things to know about ERISA appeals

The insured is entitled to a copy of the claim file sometimes called the administrative record before the appeal is decided

The insurer or plan may be entitled to discretion in deciding the appeal

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WHAT IS THE CLAIM FILE AND HOW DO I GET IT?The claim file consists of any document, record or other information that was relied upon in making the benefit decision, was submitted, considered or generated in the course of making the benefit decision, or is a statement of policy or guidance with respect to the plan concerning the denied treatment (29 C.F.R. Section 2560.503-1(m)(8))The insured is entitled, upon request and free of charge, a copy of the claim file (29 C.F.R. Section 2560.503-1(h)(2)(iii))

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HOMEWORK FOR THE PATIENTSend a letter to the Insurance Company of Plan to appeal the denial and request a copy of the claim file

Get letters of support from family and/or friends

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PLAN DISCRETION: THE FOX GUARDING THE HEN HOUSEMany plans/policies provide that the entity deciding whether to pay claims has the discretionary authority to construe and interpret the Plan and determine eligibility for benefitsThis means that the court will give deference to the decision of the Plan or insurer the decision DOES NOT HAVE TO BE RIGHT, IT ONLY HAS TO BE REASONABLEBUT when the same entity is deciding whether to pay claims, and is paying approved claims, the Supreme Court says there is an inherent or structural conflict (Metropolitan Life Ins. Co. v. Glenn, 128 S.Ct. 2343 (2008))

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The fox guarding the hen house (continued)A "structural" conflict of interest introduces an element of skepticism into what would otherwise be deferential judicial review. The degree of skepticism depends on the extent of the conflict. The types of evidence tending to show the influence of a conflict include: inconsistent or insufficient reasons for the denialdetermining a material fact without supporting evidencefailing to follow plan proceduresfailing to provide a full and fair review of the denialacting as an adversary bent on denying the claimThe more evidence of conflict, the less deference afforded to the administrator, and the more "skeptical" the review

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WRITING THE APPEAL LETTERThis letter is submitted in support of Jennifers appeal of the denial of continued residential treatment beyond March 8, 2009. We will explain the history of Jennifers disease and treatment. We trust that, after reading this letter, which carefully documents Jennifers need for continued residential treatment, you will approve Jennifers request to continue that treatment.Summarize the prior letters and documentsPoint out the inconsistenciesPoint out the irregularitiesPoint out the omissionsEnclose any new documentsConclude with specific requests

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YOUVE GOT A FRIEND . . .Hopefully during this conference, youve had the opportunity to connect with other people in the industryshare ideas and everybody will benefitIf you find yourself in a jam which you think requires legal attention, find a lawyer who specializes in this area, or feel free to contact me.*www.KantorLaw.net

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Lisa S. Kantor, Esq.Kantor & Kantor(877) 783-8686www.KantorLaw.netLKantor@KantorLaw.net

IADP RESOURCES:

www.KantorLaw.net/IAEDP_Resources

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Lisa S. Kantor, Esq.Kantor & Kantor(877) 783-8686www.KantorLaw.netLKantor@KantorLaw.net

WORKING WITH INSURANCE COMPANIES TO OBTAIN COVERAGE FOR APPROPRIATE TREATMENT FOR EATING DISORDER CLIENTS

www.KantorLaw.net

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