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Fighting Insurance for Approval

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(The following is a first-hand account from a former patient who volunteered this information. Her advice and suggestions are applicable to any of our services)

On September 27, 2012 I finally received a letter from my insurance company that didn’t make me cry, like so many letters I’d received from them before. Reading it felt a hundred times more rewarding and exciting than any college acceptance letter or scholarship reward letter I’ve ever received!

It read: 

“In response to your Level II Grievance Review Panel meeting, the external benefit panel approved your request for in-network benefits for treatment of vaginismus services by your selected providers.”

My “selected providers” were, of course, Drs. Ross and Ditza at The Women’s Therapy Center, and I think they might have been even more excited and proud than I was to finally get that letter.

Here are some of the steps I took, and tips I hope can be helpful in other women’s appeals or insurance processes in having their treatment (and cure!) recognized and covered, too.

1. First and foremost: don’t give up! If you really want to keep fighting (which you don’t have to do if you don’t want to) until your insurance company gives you the reply you want, it can start to feel like a part-time job. But at the same time, it can feel like you’re “revving up” to beat vaginismus once you get to Ross and Ditza!

For me, personally, it also served as a powerful “distraction” from worrying during the time leading up to my two weeks at WTC. (Drs. Ditza and Ross mentioned that the “fight” I put up in this bode well for my treatment and cure, and it’s true: it felt empowering to finally get that, “Oh, okay, fine, we’ll cover it!” from my insurance company!).

Take any and every letter of denial or reason given for denial as it comes, and move to whatever the next step is: a grievance, an appeal, a next-level appeal, and keep on going. Gather all those letters and your materials as stockpiles of ammunition, and hang on to everything to refer back to. The more you can say, “On this date, you said this, and on that date, Ms. X told me x, y, z,” the more powerful you feel to keep on going.

When someone tells you “there are no more steps or appeal levels,” ask to speak to someone else, a supervisor or manager, or just call back and talk to someone else until you find the next step. There’s always a next step. I’ve heard that it is “standard” for most insurance claims and appeals to be denied on the first go round, in fact, which discourages enough people, I suppose, from trying again, unfortunately. (I received several letters that read, “This is Blue Cross Blue Shield’s final determination in this matter,” before I got the “final determination” from them that I wanted.)

2. Document and cite, word-for-word. Use the literature from other doctors or in-network providers your insurance company will cover or might refer you to, rationales and correspondence from the insurance company itself, conversations and information about what your plan covers and why as you argue your case.

As it accumulates, a lot of what you’re told by different appeals analysts ends up making your argument FOR you, as it starts to contradict itself: they might require or accept one thing, and simultaneously tell you that the same thing isn’t available/doesn’t exist. Or you’d be covered by insurance if you saw a doctor (who you’ve already seen and/or who you know can’t cure you) of their choice, and in fact you can gather a lot of information for your argument by referring to that doctor’s literature or treatment options (or the lack thereof specifically related to vaginismus).

Example 1: 
My insurance company said it was not necessary for me to go to WTC because they had referred me to a “local, in-network, approved specialist in vaginismus treatment,” while also saying, in the same denial letter, that they would not cover my treatment at WTC because “there is no board-certified specialty in vaginismus.” (In my final appeal meeting, the third-party doctor who made the final approval phone call in my favor actually laughed out loud at that cyclical logic!)

Example 2: 
After I was referred to the “specialist in vaginismus treatment even though there is no board-certified specialty in the condition” (!) in my area, I referred to the intake form and procedure at that office. I was asked, repeatedly, what my “current level of pain” was, and why I had not checked which condition I was there for treatment of. The intake form listed vulvar vestibulitis, endometriosis, fibroid care, and pelvic pain, but I had to handwrite the word “vaginismus” in, and repeat (to every nurse and doctor I spoke to there) that I could not “rate the severity of my constant pelvic pain,” because I had been diagnosed with vaginismus, and not the other conditions they did treat.

Example 3: 
I Xeroxed and referred to the numerous “wellness bulletins” and reminders I’d received from Blue Cross in recent months that reminded me to schedule my annual OBGYN appointment, get regular pap tests, etc. to remind them that I was willing (but unable) to complete the preventative care the insurance company recommends (repeatedly!) and covers, and that curing vaginismus would allow me to do so. Backing that argument up were letters of support/recommendation from two different OBGYNs who had tried, but were unable to complete an exam for me, along with the EOB from the insurance company showing that my plan recognized and paid for everything but the copay for those two unsuccessful doctors’ visits. (This argument also came up in the insurance company’s definition of vaginismus treatment as being “medically unnecessary,” while regular gynecological exams are recognized and covered as “medically necessary.”)

3. Questions That Make Your Argument For You. Send copies of, or excerpts/quotes from, the statistics and “Why Choose Us” facts on the Women’s Therapy Center’s website, and other lines of logic that are hard to argue against. Ask the insurance company and the doctors that are recognized and covered in your plan the following questions.

  • Q: What is your success rate of curing patients with vaginismus? (Not treating it, but curing it?)
  • Q: Can you offer me both the physical therapy and psychological therapy required, or will I need to visit a second, or third, specialist as well, outside your office? (Does the psychologist or counselor I will have to see in addition focus solely on this condition?)
  • 

Q: How long will my treatment process last? (Can you outline my treatment program with even an estimated “end date” ahead?) 

Whatever the answers (or lack thereof) to the questions above are, the responses lead right into the next ones…
  • Q: How much will this (indefinite, no-guarantee, not-specific-to-vaginismus treatment) cost?
  • Q: This local, in-network, multi-doctor/multi-facility, referred treatment the insurance company will recognize could continue for any number of months and years, but will be covered by my plan, just because it’s in-network now? (Think about how that adds up for the insurance company!)
  • Q: Finally, how does that cost – for the insurance company, not necessarily for me, because they’ll cover it – for this treatment compare to the cost, instead, of covering my cure with the Women’s Therapy Center, in two weeks or less?

4. Additional Letters (and Voices) of Support from Professionals. If possible, send your insurance company copies of any letters of statements of support and recommendation from other doctors who are in your corner. I was so lucky to have support and cheerleading from a number of sources, and if you ask those whom you trust and know will help make your case even stronger, having their professional recommendations and arguments alongside your own letters of appeal help so much.

They’d not even met me in person at that point (!) and Drs. Ross and Ditza helped add to this stockpile of ammo, with suggestions and encouragement: 

-

  • Dr. Ross helped me formulate the kinds of questions above that built up my argument (and which helped me point out the flaws in my insurance company’s arguments at the same time!) .
  • Dr. Ditza took time out of a particularly busy day to join the conference call/appeals panel meeting (the final, successful one – no coincidence Ditza was part of it, I think!) and her voice, expertise, and arguments helped seal the deal.
  • Also on that conference call, to add more professional “ammunition” to the fight, was my psychiatrist, along with the specialist that my insurance company had referred me to (!) to help shoot down out any last scraps of an argument or questions that were brought up. But at that point, I’d jumped through all the insurance hoops, had done everything they told me to do, and had fought through every process or recourse again and again.

The third-party doctor on the call who was to make the final decision on my appeal said, at the end of the conference call, that she couldn’t even think of any additional questions, and that there was so much material and information there in front of her, supported by this great trio of professional women and their voices on the phone, she had all she needed.

5. Powerful Arguments and Logic. Here are some phrases and points from my own different letters of appeal, and from the letters my doctors so graciously wrote, that I think might have been particularly strong in making the argument. Feel free to borrow/edit to fit your needs:

  1. “The Women’s Therapy Center offers an opportunity for treatment in a concentrated and controlled environment, with a physical therapist and psychotherapist working together at all times to treat and cure this condition exclusively, something unavailable to me by any in-network provider in my (Blue Cross and Blue Shield) plan.
  2. ”

“Having identified a medical facility and doctors who fully understand my condition – and why other doctors’ attempts to help me up to this point have been unsuccessful – and who have clearly outlined and explained to me their proven treatment approach and cure, I respectfully request that you reconsider your denials for an In-Network Exception to help me complete that treatment, and finally overcome this condition.”
  3. “(Your name) has been my patient since (date), and over the course of her psychiatric treatment with me, it has become clear that her severe primary vaginismus threatens both her mental health, through an exacerbation of symptoms of depression and anxiety, and her physical health, as it has made gynecological examinations and associated medical tests impossible.”
  4. 

“(Your name) has, in therapy with me and with other practitioners in the past, participated fully in attempts to address her condition via both psychodynamic and cognitive-behavioral routes, but she has experience no appreciable improvement. I am convinced that the specialized treatment offered through the New York-based Women’s Therapy Center’s two-week vaginismus treatment program is imperative if this patient is to obtain relief from a potentially dangerous disorder.”
  5. “Vaginismus is a complex condition and, to date, there are few clinical trials to turn to for efficacious treatment options. The Women’s Therapy Center has the unique ability to provide concurrent treatment that addresses the physical and emotional aspects of the disorder under the same roof. In addition, Dr. Katz’s experience as a physical therapist specializing in the treatment of vaginismus exclusively is different than local therapists who provide physical therapy within the larger realm of women’s health and pelvic pain. More importantly, systematic desensitization has been shown to be most effective when it is able to be demonstrated and learned in a concentrated and controlled environment.”
  6. “(Your name) is suffering from vaginismus and is unable to tolerate a gynecological examination and vaginal ultrasound, limitations that may put her under medical risks. Note that it is against my ethical and professional standards to be forced into performing pelvic examinations under anesthesia when treatment is readily available from Dr. Ditza Katz, PT, PhD and Dr. Ross Lynn Tabisel, LCSW, PhD. I strongly urge you to grant my patient/your insured the needed authorization for undergoing the necessary intervention so that I can provide her with gynecologic medical care.”

Some Final Suggestions…

  • Plan Ahead/Pre-Authorization 
Have your doctor or psychiatrist apply for any pre-authorization / additional office visits under your Mental Health Benefits (whatever they are), in anticipation of the two weeks/10 days of sessions with Dr. Ross that you’ll file claims for. (Most plans with any mental health coverage have an annual limit for office visits they’ll reimburse you for, in-network or out-of-network, and if you’ve also seen a psychotherapist or psychiatrist at home this year, you might be close to that limit.)
  • Request Clarification 
Ask for all approvals and decisions from the insurance company in writing, and make sure they’re clear, with no room for error or “that’s not what we meant,” after the fact! 

My first approval letter was dated September 6, and on the last page read, “In summary: This is an exception to your Health Plan policy benefits. Your Request for In-Network benefits for services from Women’s Therapy Center for future dates of service has been approved.”  

I called (one last time!) and requested that they clarify that “summary” much further, and received the correct approval letter on September 27, reading, “…for services from Women’s Therapy Center (Dr. Ditza Katz and Dr. Ross Tabisel) for future dates of service has been approved between September 7, 2012 and September 7, 2013, for 20 visits within this timeframe.” 

(See what I meant about the whole “final decision on this matter” thing? It’s not final until you want it to be!)
  • Jump through the Hoops (But ONLY if YOU want to)
 Speaking of letting it be “final” when you want it to be, these are the steps and things I did along the way, but if you don’t want to fight through all the insurance steps, don’t! Anyone who’s been cured at WTC will tell you it’s worth every penny and then some. 

In the months leading up to my two weeks in New York, I jumped through the insurance hoops and went to the doctors they referred me to, and did what I was told. But a few times I did stop and ask myself if it was worth putting myself through another doctor’s visit that I knew was going to be stressful and upsetting, just to do it and “gather” the information I needed for my appeal. The final approval letter stated, “Approved: The Insured has followed up with all BCBS recommendations and has still not experienced a successful treatment for her condition.” So following all the required steps felt worth it then, but I was also at the point where I was just not going to take no for an answer.

You can always get some kind of reimbursement, in some amount from your insurance, even if it’s not “covered in-network” – so you don’t have to fight all the way to full reimbursement or the In-Network Exception for it all. It’s still worth it ALL when you meet Drs. Ross and Ditza.

Good luck! (Well, you might need luck with your insurance company, but I promise you won’t need it for the WTC! You’ll be cured, and it will all be SO worth it!)