Anna, you will not win your Appeal by claiming to know their finances better than they do. Even the discounted payments on your EOB’s don’t tell the whole story-- Hospitals often pay enormous kickbacks, under labels like “annual quality inspection/assessment charge”, for the privilege of being an in-network facility. The net costs to the insurance company, for transportation and ER treatment of all those lows, is probably a lot less you than you’re thinking. (DKA episodes cost a lot, but lows are cheap, cheap to treat.)
The beginning MUST invoke the formal appeal process, otherwise it goes “into your file”, where customer service can ignore it forever. The exact wording which they used in the denial is the key (even if it was very, very short). That’s what you need to refute. Keep repetition of information which they already have to a minimum-- stuff from your Endo and other treatment personel doesn’t need to be repeated again, it’s best brought up by reference (originating person date sent). You MUST demand that the response come to you, with a specific deadline of no more than 30 days ahead of the date sent.
You also don’t have to quote from the NEJM/JDRF study, or the FDA approval letters, or AACE guidelines, or anything like that: they’ve already seen it, a short reference and summary sentence is fine. With that background established, you state your case: Typically, for a denial that “benefits are not proven”, you would summarize than an MD who dares to deny this device as “medically necessary” for your treatment is claiming to be more expert than the FDA; and ignores the results of the JDRF-sponsored study in last October’s NEJM (the most respected of all American peer-reviewed journals); and feels free to ignore the findings and recommendation of your personal Endocrinologist.
Then comes your threat: “An MD who refutes all of these qualified experts and denies FDA-approved treatment, used exactly per FDA labeling, is very possibly practicing outside the scope of his/her medical competence. If the reviewing MD feels qualified to again determine that the device is “not medically necessary”, the letter which informs me of this decision will include the license number(s) and State(s) of license for that person, because I will possibly want to file a complaint with the Medical Licensing Board of that State to investigate that person’s behaviors and decisions. I recommend that you inform your decision maker of my intentions, in advance of the decision.”
Note the run-on. That’s intentional A sentence about your anger is also needed, to emphasize the threat: Every lawyer whom I’ve ever heard or read, when talking about medical lawsuits and “defensive practice” techniques, emphasizes that you need to take extra-special care of the angry pts. and relatives. Your letter needs to show you as one of those extra-angry policy holders, one who might go to great trouble to ruin a career if someone at InsCo dares to confirm the denial again.
When it’s a career, and not just money, you win. No one whom I have worked with has EVER had to follow through on such a threat.
I hope that this has been firm without being nasty to you (that’s how I intended it, just “firm”). For everyone, I hope that this longer display of appeal letter format and contents shows why your MD or nurse absolutely can’t send it. (Heck, even when an MD learns that a colleague is practicing under the influence of drugs or alcohol, it will hardly ever be brought before the Board by that physician. It’s usually handled with a personal phone call, that “… you need to stop seeing patients immediately, then retire or get treatment, or I WILL probably have to inform the board of your problem.” Direct threats of to file a complaint with the medical licensing authority, as in this letter, come only from patients and lawyers.
But only the lawyer-coached patients use the correct terminology. That’s what makes your “coached by Rick” letter utterly terrifying. (I’m not a medical professional of ANY kind, but I have listened to several relevant presentations at conferences with my DW-- an MD in a totally unrelated specialty. I know the words, especially for the case of the Nevada Board of Medical Examiners.) Please don’t make a mistake by sending an improperly prepared, un-reviewed letter. It takes many, many hour to undo the damage caused by a bad appeal letter-- a bad letter often doesn’t work, and after it fails, they’ll pick at EVERYTHING you provided in order to use it all against you at the next level.
Above all, watch your dates-- do NOT let an appeal deadline pass without taking action!