Tom Grady, MPA, ACS, ALB Director of Advocacy & Public Affairs Brain Injury Alliance of New Jersey May 14, 2015

Transcription

1 Tom Grady, MPA, ACS, ALB Director of Advocacy & Public Affairs Brain Injury Alliance of New Jersey May 14, 2015

2 adjective 1. confidently aggressive or self-assured; positive: aggressive; dogmatic: He is too assertive as a salesman. 2. having a distinctive or pronounced taste or aroma.

3 Section One: Identify resources for help with the appeals process; Section Two: List steps to be taken during the appeals process; and, Section Three: Learn to structure a persuasive message that can help you organize your thoughts and during the appeals process.

4 I am not an attorney. I assist with empowering people to advocate. I have been a members of Toastmasters of Westfield since As a part of Toastmasters International, the mission is to empower individuals to become more effective communicators and leaders. I ve learned how to develop persuasive messages over the years; inclusive of testimony before legislative bodies.

5 People who deny benefits may not understand brain injury. Let alone all the challenges brain injury can present. Let alone the unique needs people with brain injury have. Let alone that the services denied may drastically improve the quality of life for the person with brain injury.

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7 Prepare-prepareprepare. Keep a diary. Note challenges. Note the impact of brain injury on your life; the lives of significant others. Describe daily routine. Be sincere and trustworthy.

8 Your Guide to the Appeals Process, Volume 3, Patient Advocate Foundation Joseph L. Romano, Esq., New Mobility, Legal Forum, P. 54

9 Step 1: Gather preliminary information. Step 2: Understand the disability and the insurance. Step 3: Write the appeal letter. Step 4: Evaluate the result.

10 Master health insurance policy, contract Medical records Photographs, videotape Treatment guidelines Coverage definitions Doctor s narrative report Should make the case as to why more therapy is needed..and. Send enough copies to appeal committee before the hearing date.

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12 Verification of health insurance coverage Reasons for denial Information in writing is strong evidence Helps one remember important facts Hard to challenge people on paper

13 Appeals process Definitions Limitations Exclusions Experimental clauses Treatment guidelines

14 Insurance policy may have a specific time within which the internal appeal must be taken. Time limits may not be extended. Get moving!

15 This is what one needs to prove in order to successfully win an appeal. The patient needs this service because. as evidenced by

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17 Contact the National Library of Medicine Brain Injury Alliance of New Jersey Other research organizations Include with other materials submitted to appeals committee.

18 Arrange for your doctor and/or other providers to attend the hearing. Attend by phone if not physically able to.

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20 Seek an external appeal. Members of an appeal committee are not affiliated with the managed care organization. All internal appeals must be exhausted first before using an external appeal.

21 Consider hiring: A healthcare intermediary Personal medical advocate Attorney

22 Writing the appeal letter i.e., the persuasive message. Emphasizing the body of a persuasive message Helps with organizing thoughts Steps: 1. Begin with the end in mind. 2. Develop the body. 3. Create an opening / introduction. 4. Polish the conclusion / end.

23 Body [Primary points that support the main message.] Focus the presentation on one central point i.e., The patient needs this treatment. Define the main idea or point(s).! This treatment is important because! The patient needs this treatment because! The treatment is effective based on! The patient can benefit from the treatment Support the main idea or point with supportive material (ex: research etc.).

24 Opening/Introduction Catch the audience s attention (a startling question; quotation; illustration; story; display of a picture or object). Tell them what you re going to tell them; tell them; tell them what you ve told them. Acquaint the audience with the topic. Avoid small talk

25 Conclusion Provide a summary of the presentation. Reinforce the main idea. Leave on something memorable i.e., question, quote, moral etc. End on a strong note.

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