Sheri Byrne-Haber: Helping people get the care they need authorized by their insurer....

Blue Cross picked the wrong mom to mess with says Sheri. Her daughter needed surgery to address a congenital hearing impairment and the most qualified surgeon to do the operation wasn’t participating in the insurer’s network. At the time, which was about 13 years ago, that would have meant paying about $5,000-7,000 more out-of-pocket. As a single mom, that just wasn’t an option. So she appealed the decision and won – which is not all that surprising given that she is an attorney.

With this initial success behind her and a determination to help others with hearing loss have the same access to treatment, she founded a Yahoo group called AtresiaMicrotia and helped others with the same types of insurance issues she faced. The group started with just 14 members but grew quickly and now has about 2,000 participants focusing on atresia and microtia, the forms of hearing impairment that affect her daughter. She then joined a non-profit called the Let Them Hear Foundation and expanded her hearing impairment advocacy to all forms of hearing impairment. Initial growth was fueled in part by a grant from Medtronic that enabled Sheri to successfully appeal 53 denials in the first year. We continued to build on that success the following year says Sheri with more grants from companies and organizations that provide money to help expand access to care. Such grants can be found on sites including www.foundationcenter.org . With the additional funding, two attorneys and eight student interns joined the fight and in the end, completed 1600 appeals over a 4 year period. All but about 12 cases were won. More importantly, they were able to get the top 10 insurers in the country and about 12 Medicaid plans to change their medical policies for the hearing impaired, especially for those needing cochlear implants. These changes benefit at least 70% of privately insured US residents needing surgery for hearing impairment.

Sheri has found new patient groups that need similar help and is actively involved with Parents Helping Parents (http://www.php.com), a support group for parents with children with disabilities. One specific group of parents constantly facing insurance issues is parents with children who are on the autism spectrum. The biggest challenge says Sheri is to get the right people involved in the appeal. Too often health insurers use generalist to make medical decisions that need the knowledge of a specialist. It can take anywhere between 4-9 months just to get the appeal in front of the appropriate specialist. A lot of people give up, their circumstances change in the middle of the appeals process, or aren’t willing to do what it takes to get what they deserve. Self-funded plans, those funded directly by employers, are not covered under the same laws as fully insured plans. In those cases, complaints may be required directlyto the employer and in this economy, that process makes people nervous. Those close in age to being covered by Medicare will often wait to get the care they need. It’s a sad commentary on the state of our “for profit” health system when a private insurer can try to claim that something is experimental or investigational when Medicare has routinely provided access to the same care to senior citizens for almost seven years.

If you or a patient is denied access to care or if a claim is denied, you have to find out why. Sometimes you have to do a little probing to get the specific reason. Once you know the reason there are people to help you with the appeal. Start with your doctor, then look for a support group and if it’s really egregious, file a complaint with the Department of Insurance (DOI) or Department of Managed Care.

For more information about Sheri Byrne and her services, check out www.clinic-solutions.com