That is a good question. The first appeal was "free" so we didn't have to justify it with anything other than, "no really the surgery is necessary". They only gave us a rejection number on the second and third rejections and we had to request the written forms by mail, which took weeks. The written form didn't have much more, mostly boiler plate, but it did have the number (and maybe a chapter/paragraph number citation?) and on the second one it had a signature by the reviewing doctor along with his typed name, which was luckily relatively uncommon. We had to provide statements from our doctors and surgeon (who also didn't get a reason for the refusal) justifying the surgery's need and effectiveness.
From the doctor's name and the Midwest area code for review center we were able to filter down the doctor's name to a single individual and then do a search in the state medical board system (I'm not sure if this is readily available to non-medical personnel). That popped up his med school, residency, work history (ended more than a year before) and some pending issues with his performance. When we replied by registered mail we made an obvious CC to a local lawyer.
Speaking to the surgeon we were also able to makes some guesses as to the rough name/title of a justification document they would use and that along with the citation number in a google search popped up a downloadable pdf which was 5-6 years old, but seemed about right. And when we looked up the paragraph and rejection it was pretty clearly related to roughly the right kind of surgery. That let us make a more focused/documented appeal to the rejection. When they finally approved we got a bit more documentation about the prior rejections and who reviewed them. I assume ass covering.
In the end the thing that really pissed me off is that they didn't even pay what they promised to and we knew it would another 100hrs of work to get it.
Edit: we paid ~10% out of pocket on a $60k surgery + their shortchange. good news is 15y later totally successful and healthy!
P.s. this is by memory but somewhere we’ve still got that notebook and all the paperwork filed that I’d rather forget.
How on earth can some one read this and think that the American Health System isn’t fucked up?
Can someone explain to me why the model we choose to pay for the health for the populous of this country is through insurance and not straight up taxes??
Because it works well enough for them now, and they seem to have no capacity to either understand or care that others are suffering under the same system. For some, the demand for maintaining the status quo is far more cruel.
> Even on death’s doorstep, Trevor was not angry. In fact, he staunchly supported the stance promoted by his elected officials. “Ain’t no way I would ever support Obamacare or sign up for it,” he told me. “I would rather die.” When I asked him why he felt this way even as he faced severe illness, he explained: “We don’t need any more government in our lives. And in any case, no way I want my tax dollars paying for Mexicans or welfare queens.”
America's health care system is shaped and maintained by those who benefit economically from its configuration. Configuration maintenance tools include lobbying, gerrymandering, targeted tax favors, and wide dissemination of misinformation.
It's a very small fraction of "we" that maintains this status quo.
All it takes is a last name. You dont even need a first name or state I believe, although you may need a lot of patience and some luck to find the right "smith" without a state. Once you have at least a last name, you could look up the doctors specialty even practice address in the public NPES system.
Good for you though! Never though non surgeons would review surgery claims. Seems insane to me and grounds for a professional liability suit
You do need access to the state board if you want to check out complaints. i dont think You will find much though. Doctors rarely get "written up"
Good grief. I'm sorry you had to go through that, the bureaucratic trauma involved in health billing/insurance increasingly seems as bad as or worse than the medical issue itself.
It was definitely a learning experience. If you're in the hospital under a doctor's care it's a lot easier, but if you have major (expensive) preventative care, then the insurers want to discourage or delay that as long as possible.
How did you find out about the automatic rejection/identity of the reviewers?