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Cutting Edge (Sometimes Controversial) Treatments

FOUR LIFESAVING MEDICAL TREATMENTS: NOT SO “ANECDOTAL,” AFTER ALL!

Those of you who are followers of HonestMedicine will remember about the terrible time my husband Tim had after his second brain tumor surgery (his first recurrence in 10 years) in 2001. You read about how:

• Tim’s suture line wouldn’t heal for 8 months, continually bursting open

• His wound became infected and leaked cranial fluid off and on for the entire 8 months

• His neurosurgeons performed 8-9 additional surgeries (all of which failed),  in hopes of finally finding two pieces of skin that would hold together

• In desperation, his neurosurgeons took chunks of skin from other parts of Tim’s body and grafted them onto his head, in hopes that the grafts would “take,” and that his skin would finally heal. (This, too, failed.)

• Several times, his doctors put drains in his head to pull fluid from his brain

Our nightmare continued for ten months, between June 2001 and April 2002, with a 2 month break in between. Finally, thanks to a chance phone conversation  with a physician friend, Dr. Carlos Reynes, I learned about Silverlon -- an FDA-approved, 100% non-toxic, relatively inexpensive, anti-microbial wound dressing that was routinely being used by doctors to treat non-healing diabetic wounds and burns. Thanks to Dr. Reynes, Tim became the first person to have Silverlon used on a non-healing post-surgical head wound. We were extremely lucky that Tim’s neurosurgeon -- afraid that yet another surgery, which had already been scheduled, would kill Tim -- allowed the Silverlon to be put on his head.

You’ll also remember that, from the moment the Silverlon was put on Tim’s head, he began to heal. A week later, he was able to come home. He lived for another 3-1/2 years, and his incision never opened up again.

When my article about our experience with Silverlon was published by the National Brain Tumor Foundation in their Winter, 2003, newsletter, “SEARCH,” as their cover story, it created quiet a stir.

I was very careful to keep my recounting of our story upbeat, in hopes that doctors who read it would be eager to learn about Silverlon, and possibly use it on some of their non-healing patients. (This kind of non-healing suture line -- especially in cases where the patient’s skin has been previously radiated -- is more common than neurosurgeons like to admit.)

But, I also knew that if I were to tell “the rest of our story” in this article, it would never be published. I therefore purposely neglected to write about how:

• All the extra surgeries had left Tim extremely brain injured, so that when he came home, he was paralyzed, bed-bound, incontinent, and had major memory loss.

And I also decided not to tell about:

How not one of Tim’s doctors was even remotely interested in learning about the treatment that had saved Tim, and kept him from dying.

And there was more that I left out of the article, including that the residents, who had liked me very much before this incident, began acting very differently toward me: suspicious, even cold. One resident, my favorite, stopped me in the hall. “I’ve been thinking,” he said. “I just don’t believe it was the treatment that you found that healed Tim’s head.” I asked what he thought had done the trick. “Vancomycin,” he said, naming the high-powered IV antibiotic that Tim had already been on for over 6 weeks – along with several other very expensive IV antibiotics. I mentioned this fact to him. His answer – I will never forget it: “Vanco is like that. It kicks in.”

Try as I might, I could not interest one of these residents, or the attending neurosurgeon, in reading any of the materials I had brought to the hospital about Silverlon. (I even tried to share with them the FDA reports that declared that Silverlon was safe for use on ANY non-healing wound. They couldn't have been less interested. Not one doctor, or resident, read even one of the articles. A few actually told me that their “plates were full.”)

Although the doctors at the hospital where Tim’s skin had healed hadn’t seemed interested or curious about our success with Silverlon, I naively hoped that some, more curious, doctors outside of Chicago might be.

The day “SEARCH” began reaching people’s homes, distraught family members started calling me from hospital waiting rooms across the country. “My brother’s head is leaking.” “My sister’s head won’t heal.” Etc., Etc., Etc. Others sent me emails from foreign countries – all describing the same problem.

I convinced the inventor of Silverlon, Bart Flick, MD, who by now had become our friend, to talk with these patients’ family members, to offer to speak with their doctors, and to provide Silverlon free of charge for the patients. He agreed, and in at least one case that I know of, he sent the Silverlon by overnight mail.

Imagine my surprise when not one of these patients’ neurosurgeons wanted to speak with Dr. Flick. And not one agreed to let their leaking, dying patients use this product in lieu of, or even in addition to, surgery. 

For 3-1/2 years after Tim came home, I dedicated myself to taking care of him, and to obtaining coverage for the caregiver services we desperately needed, so that Tim could be taken care of at home while I worked. I also kept my home-based public relations business going so that I could afford to keep Tim at home. Even though he was very disabled, he was still Tim, and we were able to have some wonderful times.

During the year after Tim died (November 8, 2005), our difficulties in dealing with the healthcare system kept gnawing at me. I decided to create this website in Tim’s memory, and in his honor, as my way of educating others about the flaws in our medical system. I also wanted to inform people about other promising (and often lifesaving) treatments, like Silverlon, which I knew that their doctors probably wouldn't tell them about.

But “the rest of the story,” about our Silverlon experience, also kept gnawing at me, too. I kept asking myself:

• Why weren’t our doctors – and the other doctors who read about our success with Silverlon – even interested in reading about it, much less willing to consider trying it? (Remember, it was FDA-approved for all non-healing wounds.)

OTHER "ANECDOTAL" TREATMENTS

And I also wondered:

Were there other, similar, lifesaving treatments -– like Silverlon –- that doctors also weren’t telling their patients about? Treatments that were quietly saving lives (once patients themselves searched for, and discovered, them on their own), but were being under-publicized, or not publicized at all?

And, finally, I wondered:

Why aren’t these treatments better known? In other words, what is it about our medical system -- and our doctors, in particular -- that makes them so resistant to learning about (not to mention, trying) anything that is different, no matter how promising. (Secretly, I often wondered, and still do, whether these doctors have forgotten their Hippocratic Oath, and if so, how this has happened.)

Finding other, similarly life-saving treatments, turned out to be far easier than I had thought it would be. I didn’t have to look very far.

The treatments I found all have similar, very compelling, characteristics:

1) They have been around for many years, ranging from “only” 30 to over 90 years, and have benefited hundreds, sometimes thousands, of patients.

2) These treatments have all benefited extremely sick patients, with life-threatening illnesses ranging from epilepsy, multiple sclerosis, and even HIV and cancer. The results have been clear (i.e., seizures stopped, MS patients being able to walk, etc.).

3) The treatments all have medical practitioners -- and in most cases, MDs -- who prescribe the medications, and openly champion them.

4) In most cases, the patients who have benefited from these treatments are extremely passionate about helping others to learn about them.  The patients often devote a great deal of their time to doing this, holding fundraisers and educating the public.

5) And finally, some are natural treatments -- such as diets or supplements; others are off-label uses of generic drugs. But they all have one thing in common: No one is making large amounts of money from these treatments -- especially when compared to the money that is made from the treatments championed by Big Pharma.

The good news is that, for many reasons, I think that the time is finally exactly right for fixing this problem.

One of the main reasons the “time is exactly right” is that, for the last several years -- and even more so, recently -- Big Pharma’s duplicity has been making headlines. There have been media exposes about pharmaceutical companies:

• “Rigging” the so-called studies, which they themselves fund

• Hiding the results of the studies that actually prove their products don’t work, while – at the same time

• Heavily publicizing the studies that demonstrate their products’ successes

• Hiring the researchers to conduct the studies, making it very clear to them exactly what kinds of results they are expecting the studies to show

• Hiring writers to write the articles that appear in the medical journals the doctors read, and also hiring big name doctors to affix their names to these studies, while doing very little, if any, of the writing.

In fact, recently (in April, 2008), the Journal of the American Medical Association (JAMA) itself published three articles exposing the fact that Merck Pharmaceuticals had engaged in duplicitous behavior in marketing Vioxx, prior to 2004, when it was pulled from the market. Merck, as revealed by JAMA, had engaged in every one of the Big Pharma practices mentioned directly above.

Because of the media attention given to Big Pharma’s behavior, and also because of many excellent, best selling books -- such as Overdosed America (John Abramson, MD), The Truth About the Drug Companies (Marcia Angell, MD), Over Dose: The Case Against the Drug Companies (Jay Cohen, MD), and the recently published Our Daily Meds (Melody Petersen) -– I think our country is finally ready to be open to these treatments, even though they may not have multi-million dollar, Big Pharma-funded studies behind them. I think the public finally understands that such Big Pharma “studies” do not necessarily result in safe, effective treatments.

In this posting, I’ll introduce you to three very exciting treatments –- all similar to Silverlon, in that they have been saving lives for years. (One of these treatments has been in use since the 1920s, and has been championed by a major medical institution since the 1940s; the other two have been used successfully by many patients since the 1980s.)  In future postings, I’ll discuss some of the reasons doctors don’t tell their patients about these treatments – even though, in one instance, the treatment has been well known by treating physicians since the 1940s. And, in the coming weeks and months, I’ll also interview several of the people involved with these treatments. I am confident that you will find their stories – and these treatments – fascinating.

Treatment #1, Intravenous Alpha Lipoic Acid
Burt Berkson, MD, PhD.

BurtatdeskframedI first heard Dr. Burt Berkson speak at a meeting of NOHA (Nutrition for Optimal Health Association in September, 1999. His talk was a paradigm-shifting event for me.

I will never forget the true story Dr. Berkson told about how, as an internal medicine resident, he used an intravenous antioxidant therapy, alpha lipoic acid, to treat a couple who came into the hospital, suffering from acute liver failure as a result of eating poisonous mushrooms. Dr. Berkson was told that nothing could be done to save these people’s lives, except for an immediate liver transplant, and that a donor was not available. He therefore was ordered to “administer medical support” and to just observe the patients as they “went though the phases of death. I was told to take notes and prepare a report for grand rounds at the hospital.”

Not wanting to just let his patients die, he remembered reading an article about alpha lipoic acid, an antioxidant with promising potential, that was being studied at the National Institutes of Health. He contacted one of the NIH researchers and was able to get some ALA. Thanks to Dr. Berkson’s quick thinking and ingenuity, his patients survived. They are still alive today, 30 years later.

Then Dr. Berkson told (both in his lecture and his book) about how the hospital’s chief doctor, rather than showing joy and curiosity about the wonderful substance that had saved these patients’ lives, told Dr. Berkson that the patients “would have come around anyway, even without the ALA therapy” and assured him that “although these types of recoveries were rare, they sometimes occurred.”

Again, like my experience with Silverlon, a total lack of curiosity. Even a similar hostility, as you will soon see.

In his book, The Alpha Lipoic Acid Breakthrough, Dr. Berkson relates how, the next weekend, another couple was admitted to the hospital with the same diagnosis.  (Mushroom season, Dr. Berkson points out, was “in full bloom.”)

Dr. Berkson writes: "Once again, hospital authorities told me that these people had no chance of living – not with their laboratory results. The patients were assigned to my service, and I was ordered not to use ALA – the pharmacists had never heard of the drug before and it was not on the hospital list. The chief doctor added that because alpha lipoic acid was not on the hospital’s approved drug list and was not recognized by any organization that he was aware of, I could not use it again. . . . I was told either to stand back and watch the patients die or face reprimand."

Of course, Dr. Berkson was very troubled by his superiors’ attitude. He writes: “But I was a doctor charged with saving lives, and I couldn't do that. . . . I could not just sit helplessly and watch them die.” So he used the ALA left over from two weeks earlier – against the wishes of hospital authorities.  These patients, too, recovered.

What Dr. Berkson writes next sheds, for me, a very sad light on our medical system: “Not surprisingly, the hospital administration was furious with me and branded me as a doctor who could not follow orders, a person who was not a good team player.”

Soon after this, Dr. Berkson, whom I will be interviewing for HonestMedicine, left the practice of hospital-based medicine. He is now happily in private practice, saving lives in Las Cruces, New Mexico. Over the years, he has saved many patients from needing liver transplants – which he suspects may be one reason the medical establishment is not enthusiastic about his use of alpha lipoic acid. Transplants, he pointed out to me in a recent phone conversation, are a huge business in many US hospitals.

Treatment #2 – Low Dose Naltrexone (LDN)
Bernard Bihari, MD

Bihariframed Another promising treatment, Low Dose Naltrexone (LDN), is a very-small-dose, off-label use of a medication that was approved by the FDA in 1984 for treating drug and alcohol addiction. Shortly after its approval by the FDA, Bernard Bihari, MD discovered that, in small doses (1/10 to 1/20 the dose prescribed for addicts), LDN has immune-system-modulating, and endorphin-raising capabilities. He began prescribing it for patients with HIV/AIDS, and then for people with several autoimmune diseases, including multiple sclerosis, lupus, and rheumatoid arthritis. In subsequent years, Dr. Bihari also had considerable success using LDN for patients with cancers that had failed to respond to standard treatments. In many cases, the results have been stunning. Since the 1980s, several  thousand patients have taken LDN; more are finding out about it on the Internet every day.

However, while many medical doctors have personally observed extremely positive results in their seriously ill patients taking LDN, and while some of these doctors are now conducting serious trials of LDN, the majority still opt to prescribe the more toxic, side-effects-laden drugs -– most of which don’t even work well. And they refuse to prescribe LDN.

I will be interviewing several advocates of LDN, including multiple sclerosis “success story” SammyJo Wilkinson, who has been raising public awareness and money for LDN clinical trials.  (Her group raised several thousand dollars, with which they were able to fund a small trial at the University of California at San Francisco , UCSF.) SammyJo’s website is http://www.ldners.org/. Other LDN patient advocates have websites, too, as does David Gluck, MD, a very devoted physician advocate of the drug, who will help to coordinate his 4th Annual LDN Conference this year.

All of these efforts are labors of love. 

Other LDN studies are being performed, too. Last year, a paper describing the results of one study, performed at Penn State, and titled “Low-Dose Naltrexone Therapy Improves Active Crohn’s Disease,” was published in the American Journal of Gastroenterology. And two successful studies on LDN treatment for multiple sclerosis were presented at the Annual Meeting of the American Academy of Neurology this April -- one from UCSF and one from Milan. And Dr. Jaqueline McCandless has put $250,000 of her own money, and much of her own time, into conducting a clinical trial in Africa on LDN’s efficacy for AIDS patients.

In addition, SammyJo Wilkinson has coauthored a book (with medical writer, Elaine Moore), The Promise of Naltrexone, to be published by McFarland in September, 2008.

Treatment #3 – The Ketogenic Diet
John Freeman, MD; Millicent Kelly, RD
Jim Abrahams

Jimatmtgframed Finally, I will tell the very dramatic story of Hollywood film writer/director/ producer Jim Abrahams (Airplane, the Naked Gun series, and Hot Shots), his son Charlie, and the Ketogenic Diet, which finally cured Charlie of his almost-non-stop epileptic seizures – but only after he had been prescribed so many expensive, highly toxic drugs that he was literally bumping into walls. Charlie was even subjected to a completely ineffective brain surgery before Jim (through his own research) discovered the Ketogenic Diet at Johns Hopkins. Since the time when Jim found the Ketogenic Diet for Charlie in the 1990s, Charlie had been seizure-free, and Jim has devoted his life to raising awareness for the diet. He has set up the Charlie Foundation, to educate both physicians and parents of children with epilepsy. In 1997, Jim produced a made-for-television movie, “First, Do No Harm,” which starred his friend Meryl Streep, as the mother of a child whose son, like Charlie, was helped dramatically by the diet. (There are clips from the movie, as well as a short video, "Meryl Streep Introduces the Ketogenic Diet," on Jim's website.)

I’ll tell Jim and Charlie’s story in detail in upcoming postings, and I’ll interview Jim for HonestMedicine. But, in closing, I can’t resist including the reason one of Charlie’s doctors gave to NBC’s “Dateline,” for not telling Jim and his wife Nancy about the Ketogenic Diet, and for even discouraging them from trying it, after Jim had found it (even though, like most other pediatric neurologists, he knew about the diet). When asked why he had dissuaded the Abrahams from attempting the diet, he said: “because I don’t think we had exhausted all the medical approaches yet. There were actually still other medications that we hadn’t tried yet.” I could not believe what I was hearing. I urge you to watch this video for yourself. You won’t believe it, either.

When Radiation Was an Anecdotal Treatment for Cancer -- 1928

I’ll end this posting with the true story of my Grandma Julia, who was told in 1928 by Dr. Charles Mayo (when my Mom was 11 years old) that she had colon cancer, and had only 6 months to live. Instead, she went to Germany, where she had radiation treatments, and lived another 10 years! Radiation treatments, of course, would have been called “anecdotal” in America back then. (My posting about Grandma Julia is online.)

April, 2008: Some of Honest Medicine’s Most Popular Articles and Audios

1) NEW: Honest Medicine on the Blogs – This posting features several comments left on blogs, such as the New York Times’ Well Blog and the Salon.com blog, in response to postings relevant to HonestMedicine’s mission. Among the subjects these blogs and comments addressed are: patients who research their symptoms online (“Googling”); mammograms; Dr. Christiane Northrup’s appearance, discussing thyroid disease, on the Oprah Winfrey Show; doctors who “steal hope”; and the overuse of diagnostic scans.

2) Rave Review: “An Uncertain Inheritance: Writers on Caring for Family”
This collection, beautifully edited by author Nell Casey is, by far, one of the most touching anthologies on the topic of caregiving -- filled with real-life accounts by writers, some famous and some not-so-famous. Some of the best writing on this topic that I have read in many years. The book contains fascinating personal essays by such writers as: Stan Mack, Dr. Jerome Groopman, Eleanor Cooley, Ann Hood, Abigail Thomas and Susan Lehman. There is also a wonderful introduction by Frank McCourt.

3) HonestMedicine’s "SiCKO Files":

Honest Medicine's Review of Michael Moore's SiCKO, was noticed by several websites, including one that hailed it as "a superb review from someone who knows." Michael Moore also linked to it from his website!

Audio Interview with SiCKO “hitman” Lee Einer. In this interview Lee shares insurance industry "secrets" not included in the film.

Article #1 Written By Lee Einer: "Faux Health Insurance for the Self-Employed: The Sham, The Scam, The Shame of It." This is the first in what will hopefully be a series of articles written by Lee Einer, the man Michael Moore called the Insurance Industry "Hitman" in SiCKO. It was Lee's job to make sure the insurance companies he worked for were saved from paying just about ANY large bill -- no matter what he had to do. This article is truly enlightening -- and frightening!

Article #2 Written By Lee Einer: “The Truth About Self-Funded Plans.” The second in our series of articles written by Lee Einer, SiCKO’s "Hitman." In this article, Lee tells about a second kind of “insurance” that can be deceptive.

4) Honest Medicine’s Inspiration: Timothy Mark Fisher
      March 13, 1949 – November 8, 2005
My husband Tim Fisher was first diagnosed with a cancerous brain tumor in September, 1990. For fifteen years, until he died in November, 2005, we navigated our flawed medical system together. My tribute to him was written on the second anniversary of his death, and contains several wonderful true stories about Tim. He was, and continues to be, an inspiration.

5) Honest Medicine’s Audios

Ronald Hoffman, MD, Integrative Physician/Author -- In this interview, Dr. Hoffman discusses his integrative approach to the treatment of many diseases, including cancer. Also included: a discussion of the ways in which so-called "trials" or "studies" of natural treatments are often intentionally set so that they will "fail."

Nutritionist Liz Lipski -- This interview contains discussions of local/organic foods, hospital food and her books, Digestive Wellness and Digestive Wellness for Children.

Integrative Cancer Specialist Dr. James Belanger -- This innovative naturopathic physician discusses his use of blood tests and natural supplements for keeping his patients' cancers in remission.

Lee Einer, SiCKO "Hitman" -- see above

HonestMedicine’s "SiCKO Files"

_11799451836363The "SiCKO Files" are made up of a review of Michael Moore's film, along with an audio interview with SiCKO "Hitman," Lee Einer, and two excellent articles written by him.

Honest Medicine's Review of Michael Moore's SiCKO was noticed by several websites, including one that hailed it as "a superb review from someone who knows."

Audio Interview with SiCKO “hitman” Lee Einer. In this interview Lee shares insurance industry "secrets" not included in the film.

Article #1, Written By Lee Einer: "Faux Health Insurance for the Self-Employed: The Sham, The Scam, The Shame of It." This is the first in a series of articles written by Lee Einer, the man Michael Moore called the Insurance Industry "Hitman" in SiCKO. It was Lee's job to make sure the insurance companies he worked for were saved from paying just about ANY large bill -- no matter what he had to do. This article is truly enlightening -- and frightening!

Article #2, Written By Lee Einer: “The Truth About Self-Funded Plans.” Like Einer’s first article, this one is about another little known kind of “insurance,” which shares some commonalities with real insurance, but several significant differences. An enlightening article.

The Truth About Self-Funded Plans -- Guest Article By Lee Einer (SiCKO "Hitman")

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NOTE: HonestMedicine is very glad that SiCKO "Hitman" Lee Einer has agreed to write his second guest column for this site.

In his first HonestMedicine article, "Faux Health Insurance for the Self-Employed: The Sham, The Scam, The Shame of It," Lee exposed one of the insurance industries "dirty little secrets."

In this article, which follows, he exposes another.

You may also want to listen to HonestMedicine's audio interview with Lee. In it, Lee shared lots of other industry secrets. 

The Truth About Self-Funded Plans

Back in the early seventies, Congress had a bright idea to encourage more employers to provide health coverage. Congress wanted a “private sector solution,” and so they made it more attractive for employers to provide pensions and health insurance for their employees by enacting a body of legislation called the Employee Retirement Income Security Act, or ERISA.  Much of ERISA has to do with pension plans, but with respect to health coverage, ERISA made it possible for employers to pay for their employees' health coverage directly rather than paying premiums to an insurance company.

There is a lot of legal mumbo-jumbo surrounding ERISA healthcare (or self-funded) plans. Since I am not a lawyer, I will confine myself to the bare-bones basics of how a self-funded plan works, how it differs from health insurance, and how you can fight back if you need to.

FIRST, HOW IT WORKS

With a self-funded plan, an employer has a document drafted that spells out who is covered, what conditions and treatments are to be paid for, and within what limits. If you are thinking that this sounds a lot like the insurance contract you get from an insurance company, you are right. In fact, you may have gotten such a self-funded plan document from an employer in the past and not known that it wasn't an insurance company's certificate of coverage. One of the ways to identify the difference is that the document creating the self-funded plan is called a Plan Document, and the coverage description you get as an employee is called a Summary Plan Description or SPD.

The employer then puts up a pool of money to pay for the expenses described in the Plan Document. That pool of money is itself subject to risk. If, for example, five people in a small company all get renal failure or AIDS, or need heart-lung transplants, the expenses could exceed the money in the fund and the fund could be wiped out. Because of this, most self-funded plans are themselves RE-insured by a large insurance company against yearly losses exceeding a set amount. 

The vast majority of employers do not have either the manpower or the knowledge base to administer such a plan or even draw one up, so these plans are usually drawn up and administered by entities known as third party administrators, or TPAs. These days, most large health insurers are also third party administrators. So you may have a benefits summary that says “CIGNA” or “Blue Cross” on it, for example, and Cigna or Blue Cross may indeed be processing your claims. But you may not be insured through CIGNA or Blue Cross, or for that matter, anybody – because a self-funded plan is not insurance. 

“What's the difference,” you might ask “as long as they pay my claims?” Well, as long as they pay your health claims, there may be no difference from your perspective. But what happens when they don't?

One of the aspects of the self-funded plan that makes it attractive for employers is that they are exempt from state laws governing insurance. This cannot be emphasized strongly enough. Let’s say that one of your hospital bills goes unpaid for six months, and you call customer service and raise hell. They are indifferent, so you file a complaint with your state Insurance Commissioner. Your complaint will go nowhere, as the state Insurance Commissioner has no jurisdiction over self-funded plans. The TPAs know this, and it tends to make them cocky.

The fact that the self-funded plan which covers you is exempt from state law means that it does not have to provide certain benefits, such as minimum post-partum hospital stay, required under state law. A savings for your employer, but a good deal for you? Not so much.

It gets worse. Let’s say your self-funded plan knowingly refuses life-saving care for your (covered) spouse, and he/she ends up dying as a result, as happened to Julie Pierce's husband, Tracy, featured in Michael Moore's documentary, SiCKO. You are outraged, you get a lawyer, and. . . you get the other bad news: It’s tough to sue a self-funded plan.  The arena in which you will fight such an issue legally is in Federal District Court, and unlike most lawsuits, there will be no punitive damages, no pain and suffering. If you prevail, the self-funded plan will be forced to pay what they should have paid in the first place, no more. They may not even have to pay court costs.

Julie Pierce found out it was the Board of Trustees of the hospital where she worked that nixed payment on the treatment that might have saved her husband's life. She confronted them and said in her rage and despair that if it had been the CEO's spouse, the treatment would have been approved. She was probably right. One of the aspects of a self-funded plan which makes it attractive for employers is that it enables an invisible, two-tiered system of reimbursement. I once worked for a TPA that administered self-funded plans, and I can tell you that for certain plans, I was given a list of the top company officers and their family members and told “claims for these people and their family members do not get denied. Ever. There is no deductible, no coinsurance. All claims get paid at a hundred percent, it doesn't matter whether the service is cosmetic, unnecessary, whatever.”   Now, knowing that it is your employer behind this, it probably will not sit well with you that, while they denied your wife's claim for a kidney transplant, they paid for breast implants for the CEO's trophy wife.

So, that is pretty much the incentive for the self-funded plan – you get health coverage which may fail to meet the minimum requirements of state law, the plan can deny your claims with nearly zero repercussions, and can treat the company brass like kings while they treat you and your family like dreck. So let’s talk about how to fight back. Trust me, there are ways.

STEP ONE: GET YOUR SPD

As soon as possible – and before any problems have arisen -- get your summary plan description if you don't already have it. Most Insurers and TPAs play it coy, and give plan participants vague brochures “outlining” their coverage instead of providing the actual SPD.  You need your actual SPD, and if what you got wasn't lengthy, detailed, and labeled as a “Summary Plan Description,” you didn't get it.

You are entitled by federal law to receive a copy of the SPD with no foot-dragging. If your employer  does not provide you with one promptly upon request,  tell them you either need an SPD, in hand, ASAP, or you will be filing a complaint with the US Department of Labor. And if they don't comply, make good and contact the USDOL and complain. You can also sue for failure to provide an SPD in a timely manner upon request. According to DOL regulations, “If you request materials from the plan and do not receive them within 30 days, you may file suit in a federal court. In such a case, the court may require the plan administrator to provide the materials and pay you up to $100 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator.”

You need the SPD because the plan is obligated to issue benefits according to the terms stated in this document. If the SPD says it's covered, it's covered.  You need to understand whether or not the treatment or condition in question is covered, you need to understand WHY it's covered, and be able to explain in writing why it's covered, citing applicable language from the SPD. This is a major key to winning a dispute.

The SPD will also explain the appeals process which you need to follow, and the timeframes within which you will need to respond.

THE APPEALS PROCESS: FACT-FINDING

You need to get the medical records, medical journal articles, your medical Explanations of Benefits (those things the insurance company sends out that declare “THIS IS NOT A BILL”) and/or any other document which supports your position and begin to prepare your case. Your mission, should you desire to succeed, is to provide an unbroken chain of evidence and logic showing that the services which you wish the plan to reimburse are in fact reimbursable under the plan. You may need to call the insurance company or TPA and identify the underlying rationale for the refusal to pay. If you do, document every call; date, time, the name of the person you spoke with and what they told you.

SUBMIT YOUR APPEAL:

Keep a copy, and submit the appeal by certified mail or some other form, such as UPS, which will provide you with proof of receipt. “We have no record of your request” is a first line of defense with these companies.

FOLLOW UP:

The plan has a limited time to respond to your appeal. The time frame varies according to the type of claim you are disputing. Following is a summary of the time frames, depending upon the type of claim:

a. Urgent care: Urgent care claims are those in which application of the longer time frame could jeopardize life or health or the ability to regain maximum function. They also include claims in which, in the opinion of a doctor knowledgeable about the claimant's case, the delay would subject the claimant to severe pain that can't be managed without the treatment in question. Urgent care claims must be decided as soon as possible given the medical exigencies of the case, but no later than 72 hours of filing the claim. If the plan determines the claim is incomplete, it must notify the claimant within 24 hours, and allow the claimant 48 hours to submit additional information.

The plan makes the determination of whether a claim involves urgent care, applying the judgement of a prudent layperson who possesses an average knowledge of health and medicine. However, if a doctor with knowledge of the claimant's medical condition determines a claim involves urgent care, the plan must treat the claim as an urgent care claim.

b. Pre-service: Pre-service claims are those in which the plan requires prior authorization or approval. Initial benefit determinations of pre-service claims must be resolved within 15 days. The plan may seek a 15 day extension if, for reasons beyond its control, it cannot issue a decision within that time period, and it provides notice to the claimant of the need for the extension before the expiration of the initial 15 days. If the extension arises be