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My Appeal Letter

Posted by John from MN on 8/09/04 at 10:55 (157253)

Due to the high number of people requesting my appeal letter that I sent to my HMO, I thought it would be easier to post it here:

6/4/2004

Member Services Dept
Health Partners
PO Box 9463
Minneapolis, MN 55440-9463

RE: Appeal for services

Dear Member Services Department:

I have had severe Plantar Fasciitis (PF) since March of 1999. In that time I have seen over 15 doctors including physical therapist, chiropractors and podiatrist. Last year I had four surgeries with Dr. Donahue with only moderate improvement. I have followed all the previous doctors recommendation with no success.

You claim in your letter dated March 25, 2004 that HealthPartners will not approve my out-of-network costs because you claim you can provide the same services within network. If that were true than why did not Dr. Donahue, Dr. Tanenbaum, Dr. Bromin, Dr. Pastir, and Dr. Reed able to cure my Plantar Fasciitis? I did my due diligence and let your doctors try and cure my PF and have positively concluded that your services are poor and you do not have the expertise within your network to properly address Plantar Fasciitis or I would have been cured by now.

I started treatment with Dr. Sandell and within one week I was able to walk across the room with no pain, something I have been unable to do for 4 years. 3 weeks into treatment I walked a mile. 5 weeks into treatment I walked 4 miles. Today I can run 2 miles without pain. The fact is my Plantar Fasciitis is 95% cured as of to date and I should be 100% by June 18th. I would not have had to go out of network if your physicals new now to properly treat the problem.

Many of your doctors said they would have no problem curing my condition but all have failed. An attached letter from Dr. Sandell states that his treatment is 'highly specialized and is not offered by any other practitioner or clinic. Dr. Sandell has thoroughly explained to me why all the standard treatments for PF fail and why his method work.

The facts speak for themselves. I saw 5 of your doctors, had 4 surgeries, and was prescribed orthodicts, night-splints, casting, and stretching with no success. I was treated by Dr. Sandell and am now walking pain free. Therefore one could only conclude that your services are substandard and your professional need to be educated on solving Plantar Fasciitis by Dr. Sandell. It would only make sense that you add Dr. Sandell to your network since the facts are that HealthPartners lacks this expertise.

If you have any question please contact me.

Sincerely,

Re: My Appeal Letter

Dr. Z on 8/09/04 at 13:21 (157266)

John

Wow you have had alot of foot surgery. What specific procedures have you had on your feet?

Re: My Appeal Letter

John from MN on 8/09/04 at 15:34 (157285)

DR. Z

I had ESWT twice on each foot (4 surgeries), then injections where they put electrodes on your calf and put some kind of cortisone on my arch and it draws the medication into my foot, I do not know the name of it.

Of course I did the normal stuff like Orthoticts, night splints, casts, stretching, none of which effected the scar tissue in my fascia.

The doctor before Dr. Sandell told me the only alternative was to have release surgery. I am glad I did not listen to him.

John

Re: My Appeal Letter

Dr. Z on 8/09/04 at 15:52 (157286)

John,

I am also glad you didn't go for the pf release. I saw another patient post pf release with no stability left in the foot. She is post EPF.

Re: My Appeal Letter

Pauline on 8/09/04 at 17:28 (157295)

John,
I thought Dr's apply to join specific health networks. If that is the case Dr. Sandell should be able to apply to be part of this network. Often times doctor refuse to join certain health insurance networks because they don't want to accept their terms. This could be the reason Dr. Sandell isn't a member of your specific network, not that they wouldn't accept him.

This type of letter certainly lays the cards on the table nicely. Do you know if Dr. Sandell ever applied to become a member of your network???

Re: My Appeal Letter

Dr. Z on 8/09/04 at 17:33 (157296)

Pauline,

It is possible that the network is full and since Dr. Sandell is new to practice, he never had the change to apply. This is very typical for insurance companies as Aetna US Healthcare and other capitation insurance programs. They call this a close panel. No new doctor need apply. The insurance companies ask you to join as the ' need comes up'

Re: My Appeal Letter

John from MN on 8/09/04 at 17:55 (157298)

He has, he probably will be accepted in January of 05'. There are a lot of politics to play, the HMO's in MN are a little buddy buddy.

Re: My Appeal Letter

Pauline on 8/09/04 at 19:21 (157308)

John,
I think there is a lot more than politics at play too.

Re: My Appeal Letter

Dr. Z on 8/09/04 at 19:53 (157312)

Pauline,

Why do say this?

Re: My Appeal Letter

Dr. Z on 8/09/04 at 19:55 (157316)

you

Re: My Appeal Letter

Richard, C.Ped on 8/10/04 at 07:49 (157361)

That is a good letter and all, but I can almost predict where that letter will end up.

The best thing to do in this type of situation is to find out who the big wigs are and call, email and send a regular letter.