(Guest Lecture): June 2022 - Medical Appeals Insurance Workshop for Myeloma Patients/Caregivers

And I'm going to turn it over to Diana now and she's going to be able to share the why why we chose this topic. Dana. Thanks Audrey thanks to everyone who's joining us today on this very warm at least here in Kentucky, warm and humid day. The reason I wanted to cover this is because we continually get questions on our field of questions regarding the appeal process and being denied and and how to anticipate this even before you go you get a denial in the adventure getting treatment or requesting treatment, whether it's private pay or through Medicare, and you know, such as stem cell transplants a lot of times Medicare does not cover that unless you are in a certain state of the country. Unless you are in a certain staging and this and that is such an old antiquated system that they're looking at, and how you can actually best serve yourself by being proactive and how to anticipate put together appeals and put together requests for predeterminations. So, because Medicare is so complicated and it changes so much and there's different areas of Medicare when you have special needs or, you know, all these other things that Medicare, we are going to go over some of the top, or the big global micro look at what's going on. But when it gets down into the weeds. We asked that you call a financial advisor and with private pay as well. I'm sorry, a financial coach, so that we can answer your question specifically because this is all very tedious can be very long running. In fact, if we were to actually sit down and look at everything, this could go on for weeks, every day so we're going to just try to give you an overall big global picture of things you can do to increase your ability to get something pushed through. Again, we ask everybody to turn their audio off unless they're going to be asking a question and we're going to try to try to ask questions at the end. So let's get started. Appealing denied medical coverage decisions, whether it's treatment or for medications. Next slide please. So some of the things we're going to accomplish we're going to understand what the problem is you're going to be really surprised at how big this problem is and you may be one of those people who've suffered that types of appeals, the private whether it's Medicare or private pay specific steps to a successful appeal, supporting documents needed and some of the deadlines that are very, very, very important for you to look at make sure you look at the deadlines and get everything together, because if you don't do those things, you're going to be pushed out of the system. So let's get started. So medical medical coverage denials and how big is the problem this is surprising to me. AARP reported in 2018 now remember we had all these things happen since 2018 so the appeal appeals are probably even worse than that, as they are now. The 14% of all medical claims are rejected 14%. That was one out of every seven claims which amounts to a staggering 200 million a day. That's mind boggling to me. However, if you submit an appeal almost 50% of those pills are accepted, and they're approved. So if you have a self insured employer plan this number can be even higher because you can go, there's roundabouts you can go when you have a self insured employer plan that you may not even have to go to an external appeal process. Less than 2% of rejected claims are even appealed. So, it's very important to appeal those things because you have a high approval rate, if you were to appeal. Next slide please. So what is a health insurance denial, that's when you get, whether through an EOP evidence of benefits or EOI evidence of insurability. After you've gone and had some treatment or have medications, and the company going to say no we're not going to pay this and for whatever reason. So denial is when your health insurance company notifies you through that EOB or EOI, that it will not cover the cost of your medication or your treatment. So denial usually comes to you with an explanation of benefits form. That explanation of benefits form is a booklet, it's a foundation for everything you're going to do with your health insurance plan. So make sure a lot of people don't open those things because they can see it's probably not a bill. You have to open those things because if you're even paying bills, based on not looking at EOB, you may be paying a whole lot more than you need to be paying. So the appeals process has some common elements across all health plans. However, you should check your plan specific process or required information, and you're going to find that on those actually on those actual EOB or you can contact your human resources or your health insurance company to get that information. So that's a good way to get your health insurance information. So you can also go to Medicare insurance or private insurance or your plan to get the information to get the plan sponsor how that plan actually works. If you have Medicare coverage, refer to the Medicare and new handbook that you can find online at MedicareCMS.gov. Next slide. Okay, I'll just say that I have a spelling error on here. When I'm using my own eyes, I seem to go over those things over and over again because I'm using my same eyes that came out of. So I always suggest you have someone else to look it over, because you're going to miss it. And that's one of the spelling errors is one of the reason a lot of appeals are pushed out and are denied. So your current care is not deemed medically necessary or appropriate. That's one of the big reasons why it's denied. The care is viewed as experimental or investigative. And even some of those things have been out for a long time from myeloma stem cell transplants things like that can be still be denied because a lot of these things are still investigative. Clerical errors or typos. That's a huge one. Misspelling in the original paperwork or data entry errors on the claim or insurance policy numbers are incorrect. The doctor you saw was out of network. If you're selling a specialist, some of those doctors may not be in your network so you need to make sure you get approvals paperwork and verification of everything that your insurance company may have told you before you went and got that treatment that was denied that is going to help you in recovering that actual benefit. The medication or treatment was required but did not have a referral or prior authorization from your doctor. Very important. A lot of people will go over at some time your insurance company will your provider will automatically send you over and already scheduled plaintiffs to that other person that the person may or may not be in your network. And you didn't get a prior authorization completed before you saw the saw that referred doctor or specialist that could be denied. May have a lapse in coverage, or no longer enrolled with the insurance company through through when the claim was submitted, let's say you were working at a SAG, and you file the claim, while you're insured by GE, but by the time that claim gets to you're no longer working there you've dropped off for their payroll, so that claim could possibly be denied or after you've done something you wouldn't get a doctor, then it was it was declined. It's like crossing paths in the mail. So you need to make sure these things are covered. Always make sure you don't have lapsing coverage. When you're organized and missing information, your Medicare and claim number account numbers should be on all papers, everything should be there that your identifier identifier number name should be on every single piece of paper that you turn in for your pills process. Let's start going through some of these things. So again, what is appeal when you file an appeal, you're asking your insurance company to reconsider its decision to deny to deny covering a medication treatment or service for your illness, including service from people who are out of network. You can do appeal yourself or you can solicit your participating doctors office to appeal on your behalf, which is great. However, you got to understand they have a lot of people they're working with, and you don't want that timeline to expire. So again, it's very important you have short timelines to get these things done. They can also include a supporting letter as to why the treatment or the medicine is in your best interest, you can do your own personal statement and we'll kind of have supporting document as to how you can do that, as well as the doctor can put a supporting statement, as well as to why he find this treatment is treatment or medication is in your best interest. I have a question that goes along with what you're talking about right now so if you could we just ask it since this is more upsetting. So what is that time limit for which providers can submit claims. Whenever you get your ELB and it was denied, it'll tell you on that and it could it could differ, unless you need something that's expedited expedited you get after it's turned in the process the paperwork is turned in they have 72 hours to turn around, based on the need the immediate need. But sometimes it's like 30 or 60 days for them to turn around and get an answer to you. But you have to, that's when they get the paperwork so you have to look at it you have to turn in paperwork on time. And then you have, they have a certain time to get it back to you and then you have to look at the paperwork supporting documents, every time that's turned in denied and go from there. So you have to keep up with those timelines. Awesome. Great question. Thank you. And if anybody else has any questions as she's speaking again feel free to ask them. Okay and refer to your any letter they send you don't don't not open paperwork, open your evidence of benefits or evidence of insurability. The evidence of benefits well talking about is very this this, this is almost like a Bible for your insurance. It will include your mental claims details where to find an appeal and associated information may include tracking of your deductibles and maximums, because a lot of people are paying and I found out myself. I wasn't keeping up with my maximum out of pockets, and even though I wasn't keeping up with it with it with it, the insurance company, the provider may be still sending you out bills that the insurance company should be picking up 100% after you've met your And I was still paying them. So that's something to keep up with what amounts were covered and what wasn't. And do not, and I stress this again over and over again, do not pay a bill until you receive the evidence of benefits and verify that is correct. Okay, currently appeals deadlines have been extended due to covert referred to that that that denial of benefits that you got as to what that date may be those things can change, especially now that coven is not as the urgency with coven has been brought down quite a bit, but you need to verify with your medical plan as they may change at any time, don't assume anything. Okay. Next slide. So, for your internal appeals, before you go to those internal and external appeals, what you might want to do first and generally is the fastest and easiest is to request a peer to peer review that peer to peer review would be your doctor, he'll have all the supporting documentation, all the information necessary in order to talk to appear on your insurance side to see if that could be. So that's a lot faster, without having to do all the other things for your internal external appeals. And this review your doctor again will speak to another medical professional with the insurance company explain why the treatment or medication is needed and make a determination. And keep in mind that that medical professional over on the insurance side or your insurance company side, they may not be a specialist in myeloma, so they may not really understand. That is why it's very important for your doctor to have supporting documentation as to, you know, if there's a type of medication that's considered experimental or the treatment is experimental. Why is important for you specifically not necessarily for the general population, they'll they'll have supporting documentation as to how this medication is better than a previous medication. You know all of this they'll have that supporting documentation so they get that other medical professional with the insurance company can review. So a lot of times this will clear up the problem without going through the field process a lot faster. The insurance company may have a quick turnaround on their decision sometimes it'd be days or even over the phone and they can get that done. So, see if you can do a peer to peer review. First, next slide. So there's other levels of appeal that first level after the peer review, you or your doctor need to contact your insurance company fill out the appropriate documents and include all parts of the information that is the time consuming part so in mind the deadlines, and they And they'll request in writing how to read how they want to reconsider the denial. Follow the guidelines, you may have an option for more than one internal appeal and you will get that if your first appeal was denied they'll say on that denial letter it will say you can appeal again to the internal internal process, the second time, or you may then have to go to an external appeal. And as always, these are always done after your peer to peer review. The purpose of this first appeal is to prove that your, your service or medication meet the insurance guidelines and was incorrectly rejected. Now remember I said insurance guidelines, not necessarily needs guidelines right. This step of the process is typically reviewed by a medical director at your insurance company who was not involved in the claims decision at all. The purpose of this pill is approved that the request should be accepted within the coverage guidelines. Okay. It's a difference. So, independent externally, externally view an independent reviewer with the insurance company and a doctor with the same specialty as your doctor assesses your appeal to determine if they will approve or deny this coverage. And so people often turn to the external appeal with a first level or two first level appeals were unsuccessful. Again, start with a peer to peer review with all the pertinent information with your doctor because he knows scientifically medically, why it's important for you best way to go fastest way to go. And then if that is denied then you do ask for a re determination under the internal field process, maybe one or two times, your denial letter will say why and if you can go to another internal review. If the first internal review is denied, then you go to an external review. And that external review that final that that final determination, it's going to be what's going to be written in stone. Awesome. Thank you. There's just a couple questions that I want to get to before we jump into the next section of the present. So is there a limit of time for which providers can submit claims like a statute of limitations, referring to the initial claim a provider can submit to the insurance. Is there a limit of time for which providers can submit a claim for denial or research, read determination. Yeah, I'm not, I'm not sure. So, if that person wants to clarify that could be great because I think I misunderstood their question the first time. And then Cindy's question is, when you say verify the EOB is correct. How do you know whether it's correct or not. Well, when I'm talking about that you look at your EOB and then you look at what your, your doctor bills are to make sure that they actually match up and also look at your maximums out of pocket paid your deductible paid and find out if you're if your actual bill that your, your doctor is sending over, or maybe resending over it makes sure those things are correct, because sometimes they're not, they are not they may be asking you to pay for things that were not. So, there's a, there's a agreement, as far as what insurance companies pay, just because you may get a bill for $2,000 the agreement between the provider and the insurance company may be less than that. And then insurance pays off of that make sure they're not picking up that difference, or requesting you to pay that difference because you shouldn't, you're not supposed to. And I have had to do some of those pills as well for my husband because they were actually having him to pay the, the contract that the price above the contract or price with the insurance company. So make sure you look at those things. Were there any other questions. No, there was a clarification on the first question but I didn't know, Pat, did you want to say anything to that question. Are we talking to Pat. Yeah. That you need to unmute. Yeah, one question again. You did I thought I thought you were saying something so if you didn't have something to say it's okay. No, I didn't say. Okay, okay. Wonderful. And so the clarification on the first question. The very first claim before it's processed. Well, when you go to the doctor's office and they're filing a claim to have that bill paid with your insurance company. There is a time limit, and they're not going to let you know that and I didn't find out until by accident because they found to the wrong insurance company even though they had I had a new insurance card with a new provider. And so that's the time that it goes months, and it wasn't transferred over to the correct insurance company that insurance companies is up. I'm sorry, you should have paid you should have sent it to the right people we are not required to pay it. And that is not something the doctor can then go back on you to pay. That is something that they have to eat because they did not process correctly. Yeah, because the example was you know can the insurance company rejected claim because the doctor submitted it too late in that scenario, the, the pressure that the culpability is on the doctor. Exactly. Okay. Awesome. And there was a different question but it's a little bit separate so we're going to continue with this and then we can get to other questions so okay. So, when you're, when you get that denial of coverage or treatment or medication in the mail, look at your EOPS look at that denial letter denial letter. You need to request the information you're going to need all the information you need in order to file a good appeal. So you'll need to sample clay. This is a sample claim file request letter, that's going to go back to your insurance company to verify why they denied all the information they have so you can put all of your information, according to with that through your doctor's office, or you gather all the information. So here we're going to go through a sample of that file request letter. Okay, so whenever you're doing everything, your, your denial is going to be ordered. Why was denied everything so when you do that file request letter you gather this information, you need to keep it organized in the same way that it was denied and only only answer to what they're denying, don't go off on a tangent doing everything else because they're just going to get confused because they oh my god, and they're going to go over to the next claim because they have so many claims are looking at. So the first thing is always put on the top of this letter when you're asking for information, the files, say this is not an appeal. You don't want that stuff to lay over because your time is running now your clock is already started from the dialing out letter. Okay, and you need to set it by certified mail and a return receipt is requested that is a verify they received it on time because again, you're trying to verify that you did things in a timely manner. Put on the date that you send it in your insurance company that is being requested of the address, and or it says or I'd put both the facts number, your name, your member, the member name, the company that whether your insurance is sponsored through your member ID name. You can also say group number, service denied what service was denied specifically look at that denial letter is going to come that's going to be from there, your date of denial from that letter, and your provider's name who provided that service that was denied. Next slide. And then, here's your actual plead to whom it may concern. I'm writing to request a copy of all standards, policies criteria, and or any other documents involved in issuing the Nile referenced above. Okay, have that written out. Be succinct and be and make sure there's no typos. I've enclosed a copy of the denial letter, keep a copy for yourself. And then please send the requested documents to me at your address, make sure that it's not just a peel box the sitting somewhere that you want to go through every every, every other week, make sure somewhere you can get to in a timely manner because the clock is running. If you have any questions about the request, please call me at a phone number. And if that phone number you don't answer all the time. Have another phone number on there. Make sure that you know the number that's going to be calling you back. And then you can recognize that number and I say oh my god this is unusual number I'm not going to answer it, we all do that because we get all these horrible calls all day long, you can't afford to miss this number. And then you sincerely plead. Thank you so much for your time, I really appreciate this is very important to me, your name and all the enclosures that you're going to need. Next slide. So what, what should be included in the appeal letter once you've got all this information together. We're going to put appeal together, include a copy of the denial letter, be sure not to include the original make copies, keep all of your originals. So just the reasons why you meet the criteria, make sure you address each requirement separately. Be clear as to, as you can provide reference to your medical records and or doctors little letter of support include doctors level of support which he's going to use his is going to be more scientific. You may use references as to trials, or other things that's helped people that relates to your actual need provide copies of all pertinent medical records, you can gather those from those appeals that files record request, as well as request information from your doctor, include a personal statement about what this treatment means to you, we're going to go through that later on in the slides, your medical condition impact on your day to day living, etc. In reference that you are including documents with your appeal. Make sure what someone proofreads this I'm telling you I'm, I tell you right now, there's going to be a typo error in this webinar because I saw it and missed it. Make a copy of everything you send every letter or notice you've gotten from the insurance company that's pertinent to this denial. Next slide. Include on your field that appeal letter include your name, address and phone number or separate phone number again to send it certified fail return receipt requested verifying that they received it timestamped your, your, the date your, your date in your denial letter or request sent to the correct place that is going to be on your ELB. It'll tell you where to send your denial information. Include your members name identification identification number group number type of plan you have the type of plan meaning is this a self insured plan is it through an employer is a Medicare Medicaid and Medicare Medicaid is going to have their own documents now go through that later on. The date of the service quoting exactly from the denial state the criteria that the health plan applied. And so you're going to, if the request is for them to read, read, determine how they apply their criteria because you may have to go off offline like you have medicines for a second, a different use for what it was actually manufactured for. This is basically the same thing in an appeal. Next slide. So here's a sample appeal letter. You're going to have your name your address your phone number or separate phone number the top. You set it by certified mail and return request receipt. The date, your insurer name and address, patient name, name, or member name, member ID number group ID number, if through an employer group plan your plan whether it's at United Health Care, your provider, whoever provided the service the doctor, the treatment facility wherever The treatment, what type of treatment it was and the treatment date and that is all the information that's going to be on there is coming from your denial letter. So it's going to be succinctly in order from 123 don't mix. Do two before you get to, to one don't go from tip over to six then go back to four, everything has to be in order. Next, next slide. And here's your appeal. You can put it would be great if you could have teardrops on here but it doesn't work. Okay, we're talking about the US government programs how they're set up right, so I'm appealing this denial, your name of your treatment, the date of your denial for service provided requested on the date of service or the authorization of submissions. Number seven the standard that is being applied to this treatment is include all this information from the denial letter for beta. I have included a copy of the denial, a copy of the denial, not your original. I believe this Nile should be overturned for the following reasons. List each of the reasons you bet you meet that criteria that was specified that denial letter including your medical needs prior unsuccessful treatments expected result and a lot of this information if you're doing it yourself. You've gathered a lot of this information from the doctor. I've enclosed a letter of support for my doctor that states, so which is summarize the information in the doctor's letter. I have included the following medical records list the copies of the documents, not the originals, you are including. Next slide. Now this is your personal statement. This is not your doctor's personal statement. This is where you're going to say, this is why I need this treatment. This is how it's affected me on my day to day life. This is your personal plea. Next slide. Your personal statement considerations are going to include these other these listed things, some feel some people feel they are profoundly affected by their insurance plans denial of service or treatment, including medications. If this is a case for you consider whether you would like to put this in writing and a separate document, so you can keep the rest of your appeal as facts specific as possible. A lot of times this is a lot easier for the people were degree determining your denial to look at. And then when you separate your personal statement. It becomes more of a personal sense for them a lot of times they may see themselves in that situation, or may have had other people and comes to mind because they're not just looking at yours they have a lot of people, other situations they had to decide yes we're going to go through this may be exactly the same problem the other people faced. Here's some questions for you to consider when you're thinking about writing a personal statement. How long if you had this medical condition. What does this medical condition mean to you. How has your personal life been affected by this denial, Francis, you had to stop working. And if you get this treatment based on whatever information you've gotten, I may be able to go back to work because I have a family I have to take care of. How has your work life been affected. Are there other effects that you have noticed. Neurocopy this medication or treatment may help all these other things because they're not just a lot of insurance companies are just looking at what's happening now. Right. They're trying to deny or keep as much money in their pocket as possible. They're also going to look like an effect, how this is going to affect you down the road. And if this, this process may affect you later on down the road means I'm more out of pocket for them. They may be more inclined, based on your personal statement to approve it here. So, are there other effects that you have noticed, what are the short and long term effects of this denial. What other treatments have you tried unsuccessfully. What were you told by your provider concerning this treatment and again, what you were told by your provider, he's going to have his own letter of consideration as well. And then you have Medicare. So, a lot of that is a lot of appeals are very much the same, except Medicare is a lot more complicated Medicare has for special needs for all these other things that come into play you have You have Medicare standalone prescription plans you have advantage plans have the Medicare that your prescriptions plan tied into it. And all of them would you get denial letter you've got to go specifically by what that denial letter says. Okay. Important. So Medicare has a redetermination request form that you're going to have to provide for them. Next slide. So this is that request for it looks a lot more formal than everything else because we're dealing with the government right. So make sure you have the most updated form, and the correct form you can get these through the CMS.gov website, they'll have all the forms all the supplemental paperwork that you need. It is very difficult to read that you should have access to these documents are are we putting these online so people can access these. Okay, so you have access to these documents. Yeah, not necessarily online but we'll send them in that follow up email they'll have those PDF so that they can print them out. Yeah. Perfect. I'm going to encourage everybody to put that on your, put that in a file folder, so that you can refer to that because you may have one may eventually have more than one appeal that you have to get to. And if you have any specific file is easier to manage all these things right. Okay, so this is your Medicare predetermination request form is your first level appeal, and it's going to say that on the form make sure you get the correct form for the level of appeal that you're requesting. Next slide. It's hard for me to go through these but if you can see that it's very difficult to see those. So this is the second things we have evidence to submit, it'll tell you what evidence you need to submit. So, whoever's doing this paperwork for you if it's a representative, the provider, your doctor, or are you are the beneficiary of this Medicare, who's filling this paperwork out a lot of times you have to get a letter of representation, and that request you can find that on CMS line, CMS.gov website as well, because they're not just going to take information from anybody, they want to know that you have an actual representation, a representative that's doing this paperwork in your behalf. So that's one of our requirements all these other things going to play. Keep in mind there are timelines timelines timelines don't forget them don't set something aside, don't, don't not open mail, because all that mail is important. Your ELB ELB or EO I will tell you about the timeline you must adhere to when filing an appeal. So, every determination letter you will you give that you get will tell you the next steps and options for filing either another internal appeal sometimes you may have more than one internal appeal option. And as well as external and window file external appeal, where to file them addresses telephone numbers, everything to file those appeals with a Medicare plan sponsor such as at United Health Care processes, the coverage determination must. Medicare plan sponsors coverage determination must provide notice of this decision within 24 hours after receiving an expedited expedited request, or 72 hours after receiving a standard request. So sometimes the Medicare maybe even faster than your private care private pay, because they have, there's, there's so much more criteria and paperwork and things you have to adhere to with Medicare. The initial notice may be provided verbally, so long as a written follow up notices mail to the enrollee to you, the beneficiary within three calendar days of the verbal notice. So, don't just necessarily go by the verbal you want to have everything in writing before you take any other any other step. Again, timelines are important. That's, that is going to be the baseline of you getting things done on time and being appealed or denied or thrown out completely. Okay. This is the next. Okay, sorry. Yeah. Okay, so for requests for benefits requesting exceptions the adjudication timeframes did not begin until the plan sponsor receives the supporting statement from the enrollees prescriber at United Health Care whatever that prescriber is for payment requests include payment requests that involve exceptions. A plan sponsor must provide written notice of this decision make final when appropriate within 14 days after receiving a request. Now this is just for your normal standard process. If a plan determination is unfavorable, the decision will contain the information required to file a request for re determination. Now if you went through all these process the peer to peer review still do not deny go through your internal review process either once or twice and then you go to the external, and then your external is still denied. There's going to be a final determination and it's going to say, this is it we're not change we're not going back we're not talking about anymore, please do not send me in more paperwork. That is what's going to happen whether you're accepted finally or now that financial responsibility is yours or trying to find another treatment plan. And that final determination is what's going to go, what's going to happen. Next slide. So now I'm going to turn this over to Patrick Patrick has some excellent information for you guys. If you've had private pay and and and need to follow those appeals. What you need to do to even now if you don't even have an appeal pending, what you need to do to make sure you have everything at your doctor's office in line, so that if that appeal has to come up, you can get it process a lot faster. Patrick. Yeah. Hello everybody. Like in Kentucky it's warm and blue skies here in Tennessee. So, Jane asked me. First of all, I want to provide you with some success stories that I have had for me. And if you have any questions about them I would a refer you to the best practices, which is going to be the second part of my presentation. And then be. You could check with your financial approach, and either you or the financial coach could contact me for specifics and those. But then, so the second part is going to be on best practices and Diana has already covered so many, so thorough. So mine will just be adding, maybe add some more. And maybe add some more granularity. So on that generally Diana about. We're doing this more of a general fashion so you know not so specific other than my success stories. So, q amp a, and then the final financial coaches. But so for some examples that have really been successful for me, and are really impacted my treatment, you know, got me to where I am seven years out. One example was back in 2015. So I was getting my induction, you know, the standard Velcade, Dexamethasone, and Revolve. I was getting the standard treatment I was into it about four rounds. And then I went to a center of excellence, and the center of excellence doctor said well, your numbers are not going down fast enough. We need you to, we need to switch to Velcade to Kyprolis. And at the time Kyprolis is kind of new, maybe experimental off label. Well, of course, insurance denied. And so the doctor. And so I went to the doctor, and I was on the line to get a call from Mount Sinai. He did a peer to peer call, and it was accepted. And so I went to Kyprolis. And boy, my numbers shot way way down. So that really helped me with my first stem cell transplant. And then another one was in 2018. While I was having some real adverse effects from the, from the, from the Revolve. And so my doctor, Mount Sinai, my second doctor, Barton Ology, he switched me to Pomalist. Well, Pomalist is just basically it's a newer drug, but I say it's really the refined version of Revolve. And most insurance companies don't want to pay for it. They say go to the standard Revolvement. So again, Dr. Barlogy did a peer to peer, and it was approved. It was fairly easy. Another local example was at Vanderbilt here in Nashville. I had excessive drooling, which somewhat related to my alone, but also my Parkinson's. I needed Botox treatments. And he wrote a letter of medical necessity. And in fact, it was like one sentence, maybe one or two sentences. I looked at it, you know, I'm a lawyer. I'm like, what's this going to do? Anyways, it worked. They're the trick. They approved it. And then one that commonly affects us all is genetic testing. You know, this, you know, standard fish testing, especially in the beginning. Of course, that's always done and covered. But the more stringent, the more granular, the more expansive genetics often are denied. And Mount Sinai, Barlogy did some of those. So they're fairly sophisticated and not surprisingly, most of them are denied. Well, again, he did some peer to peers and that helped with the insurance company. And then he also did another thing is he worked with the provider. He had a special relationship with Signal Genetics to get where the insurance company wouldn't cover. He got them to waive them. So and then my final example, you got MRIs and scans in general. So the way I'm going, I go to a center of excellence and they generally do a series of scans every year. And a lot of you probably get the weather through center of excellence, through your local. Well, this past year, a couple of mine were denied. I'm like, what? Why? These are standard. Well, it turns out last October, I had a separate scan at Vanderbilt because they found my almost coming back in one minute. So one part of those standard slides was our standard scan was not covered. That was OK. Center of Excellence made you and and worked it out. So those are just some success stories and your stories may be different. But to go into some of the best practices, and again, Diana threw her slides. She was so thorough. So so some of these I'm embarrassed. So almost like going over some of the stuff she already did. But of course, the. No. Yeah, as she mentioned, the letter and forms for the appeals make sure I can't we can't emphasize enough. Certified letter, you know, with the signature return receipt requested. That is so critical because so many of them say, oh, you can fax it. You can upload it on the portal. Everything is easy. But you can do that. But do it as a lawyer. I would say do it as Diana suggests. And then medical records. Those are so. So I mean, sometimes the insurance company will say, well, we'll get the medical records. In fact, I'll say, since we do the we work with your medical provider and we do the billing, we'll provide it. We'll get. Well, most of the time, in my experience, that never works. First of all, they need a disclosure form. You sign off. And then second of all, they'll go. You know, I was in the hospital. I won't go into details for six weeks last spring. And they claim that they went to the doctor and he didn't provide the medical records. I said, well, that's nice. But I saw 15 different doctors. So what's doctor document should have went to the main medical records office and got the disclosure and got all the records. So I. What did they have to disclose? I got the medical records of the 40 pound box of documents, got them to them. And even then, make sure you follow up because they closed things. So they didn't get them. You know, they didn't get them the first time when they called. They didn't get them the second time when I got on the phone with medical records provider, me and them. They found out they did have the 40 pound box. But follow up is huge. Follow up, follow up, follow up on your letter, your email, whatever. And then and then be persistent or no itemized bill itemized bill is critical. And as Diana says, looking at the bill, making sure it's correct. My hospital and that six week stay, they gave me, you know, 30 page itemized bill. And I attached it to the appeals and whatever I needed to. It's hard for them to argue against that. And then be persistent, be very persistent. And then the next slide, which was Diana pointed out her slides. Not many people appeal, but those that do appeal are often very successful. But in a recent claim, somewhat medical related, critical illness related, I filed the claim. Last July, it was denied. I filed the appeal in August. And I just kept at it. Maybe it's because I'm a lawyer. But anyways, after 10 months, I finally got the tenets out of me and it was a huge one. And I'm glad I was persistent. And then, oh, and then the EOB. So on the back of the EOBs is the is the avenues that you can take. Typical ones for the private, especially are, you know, the insurance carry, of course, the plan administrator, which is often your often often your employer or your formal formal former employer. Arissa Arissa administrator where you can go. And this is Arissa administrator will I think it's a federal office will make they'll go to the employer and make the employer get all that stuff from the insurance company. You know, the reason for the denial who was involved in making this file, the education of all that stuff. And then if they don't provide it, the insurance company get $110 a day fine. So and then, then the next avenue would be the Department of Insurance in the state, like I recently went after at now for the critical illness, they were headquartered for that type of insurance in New Jersey, work with the New Jersey Department of Insurance. And then finally, you know, hired or hired on the private legal right of action. Just a few others so yeah, as emphasized the peer to peer was huge. The peer to peer with your local head. The peer to peer with us, someone from letter of excellence is even better. And how do they argue from one at one or two or one of the top 10 top 20 best doctors in my home in the country. They can't really whether it's experimental or not. One of the things that they can often. Well, again, the top doctors at the centers of excellence can say, No, it's not really experimental we're using this quite commonly. We're using it in clinical trials and it's working quite well we're rolling it out, really not experimental. Then, you know, a good example was in his off label. So there's a drug called banana class. And for some of us who have 1114 translocation. And the top experts were very well. If you realize works very well, the FDA conditional approval only. So most insurance won't cover it. But if you get a peer to peer and a top expert, generally for off what they call off label use, but they'll prove it. So even if something experimental, you can get what they call off label use. Another thing is to leverage or put pressure on the employer or the providers. So I'm on the employers, the employers have the contract with the insurance company. They have, and they want to keep you in the form, you and the existing informant players happy and they got a culture and everything. Put pressure on them and say look I've got this severe cancer and a rare case. Please work with the insurance company, put the pressure on them. Further on the provider. Like I mentioned that signal genetics and genetic testing. I put the pressure on the doctor put the professor on. They do, you know, signal genetics and all the genetic testing from Exxon. And, you know, I was saying, well, if you don't pay mind, I'm gonna tell Dr. Barlogi, maybe they'll take away. That's probably extreme. But then, I think as mentioned before, leverage the severity of our disease. I often say, multiple myeloma, you know, a rare incurable, often deadly cancer of the plasma cells of the bone marrow that destroys bones and kidneys. That sounds a heck of a lot better than just saying multiple myeloma or blood cancer. Also, I say 25,000 of us die every year. So those things can really hammer home and emphasize severity. In some cases, you know with my student loans I know that's not medical related. I said I don't know if I can live a month or not. A lot of people my support. I don't know about you, but we lose somebody in our support group probably every two months. But you throw those facts out there and you get them to move quicker. So, Patrick, that's awesome. Thank you. I'm just going to interrupt you just because we're short on time. Yeah, yeah, that's probably it. So, no, that's great. It's wonderful. And don't feel embarrassed, even if you repeated a little bit of what Diana said, you brought a lot to the table there and it's great to see it in, in real life like actually happening. So thank you so much. I really appreciate you and just excited for our audience to be able to connect with either you or Diana through our free myeloma coach program and with those myeloma financial coaches. One of the questions that I wanted to make sure we get to Darcy's experience is she's having problems being denied post ACT, a CT stem cell transplant vaccinations. So, you know, Medicare and private insurance have been rejecting them as standard as they have standard vaccines they cover for people of certain ages. And they're of course required after the stem cell transplant. So that's something that probably could be included in the letter of appeal. But do you have any experience with consulting on this Diana and another post question was build the same for part B and part D vaccines to she appeal to both Medicare or only part B and then appeal part D to the private BC. She would appeal to if it's for the medication she feels through the part D. Part D now, of course it's going to run over because it's a something required that the doctor, the doctor said you need you should have this vaccination after your stem cell transplant period, times gone by. And, unfortunately, this is because this COVID stuff and vaccinations, the bar has been moving up and down and when to do things for different, it's just never been something that's been in concrete. And because of that, it may be easier, it should be easier to get something appealed and pushed through. So, this is when it comes really important for your doctor's letter of your doctor's letter the personal letter statement from your doctor is going to play a huge role in getting those vaccinations of things done just don't do your regular appeals. Do the appeal things for your doctor because he'll have a lot more scientific information to put in there to help push that appeal. Get that field covered. And that's very important. He knows who you are he knows how medications like people, just like they're aware that COVID fascination affected people differently and laid me on my butt for like three days. And my son was fine I know other people were fine but every single fascination I got for the COVID made me put me in bed, and other people doesn't bother at all and when you have a coexisting comorbidity like myeloma or anything like diabetes on top of that, understand, and your doctor understands better than that person who's going to be sitting there in the denial on a computer desk, throwing paperwork through that letter of appeal from your doctor, saying why is personal to you why you need it. It's going to be your best line of defense for your pill. For those. I can't hear you, Darcy. Are you speaking I can't hear you. Okay, I have I do have a letter now. It was complicated by me because not me for me because I got my transplant at Mayo in Rochester, but I live in Florida, and but I did eventually get a letter from him that I haven't used yet but in the process of trying to navigate this. Medicare covers certain vaccines under part B, and other ones under part D. Now of course, the infectious disease place that I had to go to get half of these things or most of these things, just build it all together. So, and I've asked them to just kind of do it again. While I'm trying to figure out how to appeal it. But so you're saying that the thing is, my Blue Cross Blue Shield Florida Blue Cross they said, well, the reason we turn this down is because Medicare turned it down. As though if Medicare turns it down, they don't even look at it. But they said, but normally, we would cover these vaccines under part D, if, but of course I don't meet those criteria. So I'm still a little confused do I just go back to regular Medicare and put them all through with the doctor's letter, and then hopefully have it float down to Florida Blue Cross Blue Shield for the ones that are part D. Or do I separate them. Yeah, if, if, if those are ones, if that particular medication or vaccination went through their, your regular insurance and not through your part D plan. They push it through your. My regular insurance is Medicare. Okay, so versus versus. Okay, so push it through, push it through there before you go to other route. All right, push it through there with all the same documentation just make sure you're going line item by line item as to, and you got that denial letter. Keep all those things together and put those. Even if you guys know that from the other side now you're pushing through the other side, all those things together. I mean I didn't get a, I don't you know these terminologies. I know, I know, a bill, you know, from the infectious disease play saying, you know, you're not we're not being reimbursed for this you need to pay. And, you know, my first concern was, they said, you know, you'll go to a, we'll go to a credit bureau in 99 days, how much is it. It's just adding up by the day it's up to about 1500 it's small potatoes compared to hats 40 pounds of six weeks in the hospital. So my question why is it why is it adding up by the day, what's adding up, because the infectious disease place puts it through to Medicare and then they send me more bills with more stuff as they're putting through because I've been getting these inoculations since January, you know, and they're spaced out by two months each, so it just keeps happening and I've tried, I sent the letter to the infectious disease people saying, use this letter from Mayo instead of just putting this through like I'm going on a vacation to Africa. I don't need a polio vaccine because I'm going to an exotic place. Anyway, here's, here's, let me give you this because you're very complicated. If one of those complex, what I would suggest you do is reach out to co patient. Okay, co patient, see, see all pat nt.org or triage cancer, they partner with co patient. Send all this to them, including the denials and everything how is bill at adding up and have them fight this battle for you there may be, they weren't doing it for free for a lot of people for the first year. Have them look at it and see what they can do to help you. Okay, as I hear in this group had this experience I would imagine a lot of people have had a transplant. Welcome Darcy you get the rose for the day. Well I just wonder if I done it, you know through Mayo or or transplant center, but I didn't have that option because we don't live in the transplant center and I know this was coming around the bend. Yeah. So, please reach out to them and ask them what they what they will suggest a lot of times they can help you with that process. Okay, thank you. That's your welcome. Yeah. Oh somebody asked a question about real quick. I thought co patient was on there but it wasn't. I did time it into the chat though. Let me let's say a couple other questions quickly. Can you cover a tele visit with a new specialist or a second opinion to guide current oncologist. Good question. A lot of times they will, they will, they will pay for second opinions. But you might want to have your doctor test what it is doctor reach out to them first, almost like a pre certification process. Yeah, it's done. It's better to do it ahead of time versus behind after the fact. Yeah, and and again, it does it does depend. So I think working with the Miami financial coach, making sure that you're prepared because you don't want to, you'd rather be proactive than have to right correct things in the past. I have a personal experience with that. I had a second opinion from Dr Jaganath, Pat Kelly's talk to her and that was covered. And I also had an initial new patient interview by zoom now with an oncologist. You think because I was moving up from Florida to Illinois and I needed to talk to him and get on board so I could get my new relevant prescription. And that was covered as well. So I, I mean, personally, I'm no expert on this one. But if you're concerned, I would ask before you go. Has this been cleared with Medicare or would be insured before you go? I know with private insurance people have more difficulty with getting second opinions than with Medicare. So thank you Darcy for sharing your personal experience. That's helpful. I'm going to ask about Center of Excellence. The Center of Excellence, they specialize in something like myeloma or, or heart transplants or things, and they are recognized by their peers by the community as being a center of excellence for providing extremely good care and that's what a center of excellence is considered. So MD Anderson, yes, is considered to be a special center of excellence. That's a great question. There's lots of different specialty centers, we can even send a link. Another question, why are itemized bills so hard to get? Is there a proper terminology to ask for it? I've asked billing departments, they have no idea what I'm asking for. It's not that they don't know what you're asking for, is they may not want to provide it. Every person in billing know what an itemized bill is. That is for every single procedure, every single medicine you got is itemized on that list. They know what it is. Yeah, be persistent and ask somebody else or their manager or something if they're feigning innocence there. Okay, and then Sydney's question with the peer to peer, how do you get your specialized doctor from large cancer center to do this on your behalf in the appropriate timeframe? It's hard enough getting questions answered within a week. Is there a special department in these cancer centers where they can help you with this? Patrick, with Dr. Jagannath, did you just have a good relationship with him or what was the process of asking him to do this peer to peer on your behalf? Yeah, extremely lucky. Yeah, good relationship. In fact, Dr. Jagannath and Dr. Barlo even gave me their cell phone numbers. I know a lot of doctors don't do that. But I think he also worked with my local oncologist. In fact, when I was in the exam room for my first visit with Dr. Jagannath, he called my local and I was in my office with my local and they built a relationship. So that was one way. And then also with Barlogi, he had a long term administrator, Bonnie, he had for like 30 years. And he was Bonnie was the go to person. You needed anything to get done, you got Bonnie and Bonnie would arrange that peer to peer get it done. So if not the doctor, try to find out who that go to person is, whether it's administrator, chief nurse, whoever it is. And that's why I would include in your best practices, Patrick, make connections at the clinics that you're at, because doctors always change. And it's true, even nurses change. But if you're making connections with these people, that can be vital for you getting the best care and making sure that you're being proactive, like Patrick was saying, and having that really synergistic relationship between the specialist and the oncologist, so that they can advocate on your behalf and make decisions together. I mean, that's vital. So that's part of best practices as well, just making sure that you're being an empowered patient, going out of your way to make connections at the clinic, be personable, be kind, even on deck stays, you know, so just things like that. Another thing real quick, whenever you go to the doctor, if you have a my chart, and everybody has to use you have a my chart to whether your doctor specialist, go on there after the meeting and they will split their notes in there, go in there and look at those notes, make sure that everything you use told them talk to them about our on those notes because that's part of the records, if you need to request records are going to be in there to help with denial with appeal, re determinations. Great. Did you want to go over the summary, Diana, and then we can finish that? Sure. So, every person who has insurance have a legal right to challenge your coverage denial. Every plan, including private policies, employer sponsored health plans, self insured plans, Medicare, Medicaid, all of those plans has a have a process for reconsidering reconsideration of any adverse determination or coverage by the plan. The process may be tedious, but it's well worth the effort again to remember the number of claims that are up 200 million a day that are denied and only 14% of people even try to request an appeal and more than the more than 50% of those are generally approved. So if you cannot do it, appoint a representative that can help assist you gather documents, putting everything together. You'll need to file a sign authorization form from your health insured that will authorize that communication with that representative on your behalf. And these forms can be also be found on your health plans website at the CMS, CMS.gov, have that representative letter request for representative on there as well. Remember there's HIPAA that's involved with all these information. That's why they required a lot of these documentations. These are resources for you to go to. A lot of these things are on our, our, our sites at health, health three dot, health three dot org, or thank God, health three dot org. But reach out to those and again I mentioned co patient co patient.org is another place triage cancer.org is another place for you to go to for legal information for and they will talk to you, the Joanna Morales, those people that will talk to you personally, they will refer you to things that you have problems with. They are a great resource. I'm telling you, I cannot express this enough, how greater resource they are. So please reach out to them, get online and look at them as the information you can get from them as well. Definitely and we'll include those in the follow up email with those different resources that we've mentioned. This has been an excellent discussion. Thank you to the audience for your participation. Thank you to Diana and Patrick for your preparation and your authentic sharing of information. You can join us next week in the myeloma financial chat next week. No, Diana don't get scared. On July 5 for the real cost of caregiving and caregiver benefits and we're going to be joined by the myeloma caregiver chapter, we're going to be joined by the AML acute myeloid leukemia foundation caregivers. So we're really looking forward to that. Upcoming events you might be interested in. We have the non-secretary myeloma community chapter tonight talking about measuring serum BCMA for non-secretary myeloma. On the 21st is our plasma cell leukemia chapter we're going to be just connecting, talking about updates in the PCL field. And then the 21st at 7pm is our amyloidosis chapter launch with Dr. Jeffrey Zander so I'm really looking forward to that. The link to sign up for those events and much more events that I did many more events that I did not mention today is found at the bottom of the slide and will be found in that follow up email I've been mentioning. Another thank you to our sponsors for some of our script GSK Genentech Janssen oncology and AbbVie. And again just a big thank you to you for helping us build this myeloma community events group and we hope you have a great rest of your day. Thanks. Bye everyone. Thank you. Thank you.