Let Them Hear Foundation

[LTHFAdvocate]

Boy, I disappear for two months (my house almost burned down and right after that, I had to have surgery) and all heck breaks loose.

Thank goodness someone had the common sense to actually contact me (BTW, ALL of my contact information is available online) to let me know the lies that were being posted about the Foundation.

Jillio, I'm sorry to say you clearly have no clue about the financial operations of either non-profits or cochlear implant centers. Cochlear implant centers are a MONEY LOSING operation across the board. I don't know of a single CI center in the US that is operating at a profit, and I'm pretty familiar with most of them. 75 % of the 1200 people at the CI conference in Charlotte this past April cited financial losses as their number one concern about the ongoing operation of their implant clinic. Every CI surgery we do, we lose money. Period. In general, hearing aids sales, service and maintenance are far more profitable to otology clinics than CIs. So your statement that

I am simply pointing out the truth behind the organizations efforts toward CI as opposed to HA. The motivation has nothing todo with altruism, but is based on financial gain.

could actually not be FARTHER from the truth. If you want the truth, check with the person who KNOWS the truth, don't make up something that fits with your view of the world and then put the "truth" label on it with zero fact checking.

That does make alot of sense. CI does cost alot more money than HA therefore they would have more to gain by supporting them than the HA company would.

Sorry, it doesn't work that way either. The facility where the implant surgery is done is the one that buys the CI and charges the patient for it. Not the surgeon, or the medical clinic or the audiology clinic. If there is "profit" to be made from the sale of the device (and really there isn't, a lot of these facilities are getting reimbursed $6,000 or even more under their cost of the device) it is not being made by either your surgeon or your audiologist.

If implants are not done, they loose their main source of finanacial support.

Since we lose money on implants, that argument is completely specious.

What we need is a deaf advocate that will advocate for HA and medical insurance coverage

I guess you missed the part where we do advocate for HAs, services, and other non-CI related issues? We are barred by law from lobbying for legislation, we can assist other people who want to try to get laws passed (which we do all the time) but we can't undertake trying to get legislation passed ourselves.

But the fact of the matter is, had their not been financial incentive for them, they would not have been there to assist you. To believe that you were helped simply because they are caring and sensitive people is naive.

Remind me again what my financial incentive is? The foundation doesn't make money on implants, doesn't charge for most appeals, doesn't make money off the device, and 97 % of our appeals patients go to clinics other than ours. So, no financial incentive there. Let me think, it must be MY personal financial gain. Except that I work 80 hour weeks, answer e-mail at 10 pm at night, and my salary is about 1/2 of what I would be earning if I were working at a firm or as corporate counsel at a for-profit.

How about this as an answer? Eleven years ago, Blue Cross completely pissed me off by withholding approval for my daughter's hearing impairment related surgery for seven months. My daughter finally got her surgery, and gained five grade levels in reading in seven months after the surgery, and I was so overjoyed that I made a commitment to myself and God that every family who wanted this should have the same opportunities my daughter had, and not just because they happened to have a mom who was a lawyer with resources available. That's when I started doing appeals for free (that was about 1000 appeals ago, BTW).

And the big offices,e tc. that you speak of do nothing in the way of helping a population of people needing service

And that is exactly why the Advocacy Program is not co-located with the clinic, we are in the "low rent" district in a very industrial section of Menlo Park.

It sets precedence, vallee. And once precedence is set, it provides them with a foundation for their legal arguments.</QUOTE>

Uh, no it doesn't. Getting denials overturned are almost always good for that patient only. Not one of our cases (even the handful that have gone to court) have set any type of legally binding precedent. If it did, why would we still need to be arguing the same points over and over and over again with the insurers? We would have been out of business with our first bilateral CI win in 2004 using your logic.

The legal department still gets paid for the assistance they provide, and the assistance they provide sets precedence so that they may more easily achieve decisions favoring implant from courts.

How do you remove the emotion from an argument? Stick to the facts.

You ought to consider following your own advice Jillio, since your "facts" are so far from the truth. We don't get paid for the assistance we provide (VERY rarely, we get reimbursed for fixed costs) and the rulings don't set precedence.

Would this foundation help me, as a HA user, get new HAs or digital HAs?

Yes, though right now due to our crushing workload and lack of funding, we are only accepting HA appeals for children. Too bad we aren't making those amazing profits that Jillio keeps talking about, then we COULD do HA appeals for everyone.

But can't you see, vallee, that this places some people in the position of making a decision for CI that they would not otherwise make because it is the only way that they can receive assistance? I personally see that as very manipulative.

As Vallee pointed out, we only accept appeals after a denial has already been issued. Therefore we have no involvement with the person's decision to get an implant, that decision is made generally months before people come to us for help.

There also seems to be a lot of confusion regarding the sliding scale. That has zero to do with the advocacy program. The sliding scale is for clinic patients, not advocacy program clients. We have clinics in Palo Alto and San Ramon, which is why the sliding scale is just for those areas. The advocacy program is currently only charging for patients who have selected Cochlear devices, and that is only because we've run out of funding to cover the costs of those appeals. All other appeals continue to be free.

And they advocate for insurance payment in order that they receive the insurance payment from their patients

Wrong again. Remember, 97 % of the advocacy program clients (like Vallee) are patients at OTHER clinics, so those patients provide exactly zero money to the clinic. Even for the 3 % who are clinic patients, we are not contracted with any insurers, therefore, the clinic never receives insurance payments, the payments go directly to the families.

why the need for all the board members and employees with financial management backgrounds if they have no profits to manage

You must be joking. Remind me again how a non-profit can have "profits to manage"? We have budgets, we have fundraising, we write grant applications, and we try to manage our limited money to the best of our abilities. Frankly, I am GRATEFUL we have such experienced board members and staff committed to this cause, otherwise, we would be able to help far fewer people.

Stick to the facts people, not what you just imagine the facts to be.

Sheri

 

[vallee]

thank you Sheri.

 

[jillio]

Boy, I disappear for two months (my house almost burned down and right after that, I had to have surgery) and all heck breaks loose.

Thank goodness someone had the common sense to actually contact me (BTW, ALL of my contact information is available online) to let me know the lies that were being posted about the Foundation.

Yeah I figured that Vallee would email you sooner or later.

Jillio, I'm sorry to say you clearly have no clue about the financial operations of either non-profits or cochlear implant centers. Cochlear implant centers are a MONEY LOSING operation across the board. I don't know of a single CI center in the US that is operating at a profit, and I'm pretty familiar with most of them. 75 % of the 1200 people at the CI conference in Charlotte this past April cited financial losses as their number one concern about the ongoing operation of their implant clinic. Every CI surgery we do, we lose money. Period. In general, hearing aids sales, service and maintenance are far more profitable to otology clinics than CIs. So your statement that could actually not be FARTHER from the truth. If you want the truth, check with the person who KNOWS the truth, don't make up something that fits with your view of the world and then put the "truth" label on it with zero fact checking.

Non-profit only means that any money showing in the back at the end of the fiscal year must be dispersed. It is perfectly legal to disperse these funds as very large bonuses to adminsitrative employees.

And the greater number of CI surgeries done, the less the chance that you will continue to show an overall loss. The more precedence that is set through litigation, the greater the probability that you will not have to litigate with that particuar insurance company again, thus teducing the amount spent out to get the implant apporoved and insurance payment tothe physician and the clinic made automatically upon filing of the claim.


Sorry, it doesn't work that way either. The facility where the implant surgery is done is the one that buys the CI and charges the patient for it. Not the surgeon, or the medical clinic or the audiology clinic. If there is "profit" to be made from the sale of the device (and really there isn't, a lot of these facilities are getting reimbursed $6,000 or even more under their cost of the device) it is not being made by either your surgeon or your audiologist.

I have already stated that the clinic purchases the implant and charges the amount back to the patient. Additionally, the cost for medical services involved in the surgical procedure and physician fees are added. That is why yopu advocate for insurancer payment. In order that the clinic be paid at at least an 80%, if not greater rate, for the the costs incurred. Payment from the insurance carrier is made to the clinic, not the patient. So, lets see......a $50,000 total cost for an implant surgery, insurance coverage at an extimated 80%. The result? A $40,000 payment to the clinic.



Since we lose money on implants, that argument is completely specious.

Loosing money on the actual implant is negated if one is making profit ont he other activities associated with the promotion of the CI. And LTH appears to have their fingers in several pots associated with the promotion of CI surgery and oral philosophies.

I guess you missed the part where we do advocate for HAs, services, and other non-CI related issues? We are barred by law from lobbying for legislation, we can assist other people who want to try to get laws passed (which we do all the time) but we can't undertake trying to get legislation passed ourselves.

Nope didn't miss it at all. In fact, I have asked you specifically for the ratio of HA litigation to CI litigation that is undertaken by your agency.



Remind me again what my financial incentive is? The foundation doesn't make money on implants, doesn't charge for most appeals, doesn't make money off the device, and 97 % of our appeals patients go to clinics other than ours. So, no financial incentive there. Let me think, it must be MY personal financial gain. Except that I work 80 hour weeks, answer e-mail at 10 pm at night, and my salary is about 1/2 of what I would be earning if I were working at a firm or as corporate counsel at a for-profit.

I said financial incentive of the organization, and you are not the entire organization, but simply an employee of that organization. Regarding the nature of your salary, you are still being paid to provide legal representation, whether you could be making more at another agency or not. Where you choose to work in order to receive that salary is your choice. The facto f the matter is, you are not working for free, and therefore, are not providing legal services inthe form of appeals for free. And those appeals still result in a clinic and a physician being paid by an insurance carrier. Nothing free going on.

How about this as an answer? Eleven years ago, Blue Cross completely pissed me off by withholding approval for my daughter's hearing impairment related surgery for seven months. My daughter finally got her surgery, and gained five grade levels in reading in seven months after the surgery, and I was so overjoyed that I made a commitment to myself and God that every family who wanted this should have the same opportunities my daughter had, and not just because they happened to have a mom who was a lawyer with resources available. That's when I started doing appeals for free (that was about 1000 appeals ago, BTW).

Appeals for free? You don't get paid a salary through LTH? If you are being paid a salary to undertake these appeals, then you are hardly doing it for free. And if it results in an insurance payment to the clinic, your salary is being offset by that income. If financial consideration was not invovled, you would not be on retainer. If all of these services were being provided "for free" then payment from insurance companies, or patients, would not be an issue.
And that is exactly why the Advocacy Program is not co-located with the clinic, we are in the "low rent" district in a very industrial section of Menlo Park.
What exactly does that have to do with anything?

It sets precedence, vallee. And once precedence is set, it provides them with a foundation for their legal arguments.</QUOTE>

Uh, no it doesn't. Getting denials overturned are almost always good for that patient only. Not one of our cases (even the handful that have gone to court) have set any type of legally binding precedent. If it did, why would we still need to be arguing the same points over and over and over again with the insurers? We would have been out of business with our first bilateral CI win in 2004 using your logic.
Are you telling me that you don't cite precedence in your appeals? It is not legally binding, but neither is any other precedent unless it results in a change in law. However, precedence is used as support for a legal argument. And the more cases for which you can cite precedence the more support you have in presenting your case. And that is with those cases that go to court.

So, your appeals are not taken through the legal system, but simply a settlement arrived at between LTH and the insurer? That further decreases the costs involved with an appeal.So, you are simply mediating? No wonder you have those on your board with extensive employment histories in the insurance field.



You ought to consider following your own advice Jillio, since your "facts" are so far from the truth. We don't get paid for the assistance we provide (VERY rarely, we get reimbursed for fixed costs) and the rulings don't set precedence.

But you get paid for your mediation through salary. The physicians and the clinics get paid by the insurance carrier as a result of your mediation. So, who is it that is going without pay?



Yes, though right now due to our crushing workload and lack of funding, we are only accepting HA appeals for children. Too bad we aren't making those amazing profits that Jillio keeps talking about, then we COULD do HA appeals for everyone.
But I thought you were doing appeals for free. Is that only the CI appeals that you do for free?



As Vallee pointed out, we only accept appeals after a denial has already been issued. Therefore we have no involvement with the person's decision to get an implant, that decision is made generally months before people come to us for help.


There also seems to be a lot of confusion regarding the sliding scale. That has zero to do with the advocacy program. The sliding scale is for clinic patients, not advocacy program clients. We have clinics in Palo Alto and San Ramon, which is why the sliding scale is just for those areas. The advocacy program is currently only charging for patients who have selected Cochlear devices, and that is only because we've run out of funding to cover the costs of those appeals. All other appeals continue to be free.

And that is exactly my point. LTH has their finger in many more pots than simply the advocacy program. I am talking about the entire organization, not just their advocacy efforts. Of course, it is good PR to concentrate on those as they make a good human interest story and evoke an emotion response from the reader. But it is but one small part of the whole.


Wrong again. Remember, 97 % of the advocacy program clients (like Vallee) are patients at OTHER clinics, so those patients provide exactly zero money to the clinic. Even for the 3 % who are clinic patients, we are not contracted with any insurers, therefore, the clinic never receives insurance payments, the payments go directly to the families.

So the family pays up front, and the insurance company reimburses them. Either that, or you contract directly with the patient or the family to deferr payment until the family receives the insurance disbursement, at which time, they sign the insurance dfisbursement over tot he clinic.



You must be joking. Remind me again how a non-profit can have "profits to manage"? We have budgets, we have fundraising, we write grant applications, and we try to manage our limited money to the best of our abilities. Frankly, I am GRATEFUL we have such experienced board members and staff committed to this cause, otherwise, we would be able to help far fewer people.

Non-profit does not prohibit you making a profit during the year, but only that you not be showing a profit at the end of the fiscal year. Any money in the coffers that has not been used for expenses must be disperse, usually to upper level employees at the adminsitrative level.

Stick to the facts people, not what you just imagine the facts to be.

I agree....let's stick to the facts.

 

[jillio]

Now how about answering the question posed regarding the ration of HA appeals to CI appeals specifically as applied to LTH? Sicne the population of deaf as a whole has more HA users than CI users, the appeals should show a greater ratio of HA appeals if the intent of the organization is to serve the deaf population. However, if the intent is to serve only the CI deaf population, then the ratio would show a much greater ratio of CI appeals.

 

[jillio]

thank you Sheri.

And, thank you, vallee.

 

[vallee]

Yes,, I did e-mail Sheri. That tells you at least there is communications between us. I was respected enough that I am a person not a case, not a number. How many people can say that with organizations? Also I hope she did answer your questions. I am happy that an organization like LTHF is around to assist me and others.

 

[loml]

Sherri & Vallee -

 

[Tousi]

Sheri, sorry to hear about issues with your home and health. Hope all is back in good order and you have a Merry Christmas.

 

[LTHFAdvocate]

Yeah I figured that Vallee would email you sooner or later.

Too bad you didn't have the common courtesy to contact me before you started spouting off "facts" about a foundation that you clearly know very little about.

Non-profit only means that any money showing in the back at the end of the fiscal year must be dispersed. It is perfectly legal to disperse these funds as very large bonuses to adminsitrative employees.

Large administrative bonus? I hope you can hear me laughing all the way from California. If such a thing did happen, which it hasn't, it would be reported on the Foundation's 990 tax filing, which is publicly available on Guidestar. You won't find anything like that there, because, hmmm, it doesn't exist. And is that definition of a non-profit you provided another one of your "facts"? If so, the IRS would differ with you, their definition (which I'm pretty sure IS a fact) is at Exemption Requirements

And the greater number of CI surgeries done, the less the chance that you will continue to show an overall loss.

Last time I checked, when you increase the amount of an activity that you do that is causing you to lose money, it increases your loss, it doesn't decrease it.

The more precedence that is set through litigation, the greater the probability that you will not have to litigate with that particuar insurance company again, thus teducing the amount spent out to get the implant apporoved and insurance payment tothe physician and the clinic made automatically upon filing of the claim.

Right, that explains why it took over 100 cases against Blue Cross before they changed their policy. You clearly haven't reviewed how our advocacy program works, or googled our Foundation. While we take what we consider to be a "legal" approach to our appeals, we have never filed litigation. Also, you keep on referring to legal representation, which our program specifically does NOT provide. We are insurance advocates.

I have already stated that the clinic purchases the implant and charges the amount back to the patient.

And you continue to get it wrong. I have already stated, and you either don't understand or continue to ignore, the fact that the facility where the surgery done is responsible for the purchase and billing for the implant, not the medical clinic or implant center. In this regard, CIs are no different than pacemakers, hip replacements, or any other surgically implanted prosthetic. On rare occasions and only at universities, the surgery facility might be the same business entity as the implant center, but the vast majority of the time there is no connection either financial or otherwise between the surgery facility and the implant center.

Additionally, the cost for medical services involved in the surgical procedure and physician fees are added. That is why yopu advocate for insurancer payment.

I'm so glad I have you to interpret for everyone the reasons in MY mind behind why I do the things I do. This statement is wrong. Enough said.

In order that the clinic be paid at at least an 80%, if not greater rate, for the the costs incurred. Payment from the insurance carrier is made to the clinic, not the patient. So, lets see......a $50,000 total cost for an implant surgery, insurance coverage at an extimated 80%. The result? A $40,000 payment to the clinic.

That's amusing. Have you ever actually LOOKED at an EOB for payment for cochlear implant surgery? The average amount paid across the US by insurers is about 31 %, not 80 %. And when you take the device out of the equation, because the surgeon and the clinic do NOT bill for or get paid for the device, the amount works out to about $2000 , which is just slightly (95 %) below your $40,000 "fact". And payments are always made to patients when the insurer is not contracted with the clinic.

Loosing money on the actual implant is negated if one is making profit ont he other activities associated with the promotion of the CI. And LTH appears to have their fingers in several pots associated with the promotion of CI surgery and oral philosophies.

We don't charge for training, and when people can't afford our clinic services, we give them away for free. Hardly the approach of someone trying to profit off of other activities associated with CIs.

In fact, I have asked you specifically for the ratio of HA litigation to CI litigation that is undertaken by your agency.

Must have missed that somewhere amongst your 54 posts in this thread, sorry. #1, we've never litigated a case ever, so you asked the wrong question. What you meant to ask is what is the ratio of HA appeals to CI appeals. CIs currently represent about 2/3 of our cases, which means we've done several hundred non-CI cases. This ratio is actually dropping pretty rapidly since we've been able to get over half of the insurers in the US to cover bilateral cochlear implants without appeals, we are doing more and more non-CI appeals every day because we are doing fewer CI appeals.
[/COLOR][/QUOTE]

Regarding the nature of your salary, you are still being paid to provide legal representation, whether you could be making more at another agency or not.

Actually, I'm not being paid to provide legal representation at all -- see my comments above.

And those appeals still result in a clinic and a physician being paid by an insurance carrier. Nothing free going on.

Yes, *A* clinic and *A* physician might receive financial compensation when we win a case. But 97 % of the time, it is not a clinic associated with either CEI or LTHF. The 3 % of the time that a CEI physician benefits, CEI pays the Foundation for the costs of the appeal. CEI physicians are the only physicians in the country who have to pay the foundation for an appeal, how's that for irony?

Appeals for free? You don't get paid a salary through LTH? If you are being paid a salary to undertake these appeals, then you are hardly doing it for free. And if it results in an insurance payment to the clinic, your salary is being offset by that income. If financial consideration was not invovled, you would not be on retainer. If all of these services were being provided "for free" then payment from insurance companies, or patients, would not be an issue.

I have never personally received compensation for doing an appeal in the eleven years I've been doing this. In fact, for the first seven years, I didn't even receive a salary. I am not on a retainer, my salary is not based on how many appeals we accept. And I've already said that the appeal never results in insurance payments to the clinic. Yes I get a salary (now), which is below market that I work very hard for. That doesn't introduce anything that suddenly invalidates the benefits of the appeals program.

Are you telling me that you don't cite precedence in your appeals? It is not legally binding, but neither is any other precedent unless it results in a change in law. However, precedence is used as support for a legal argument. And the more cases for which you can cite precedence the more support you have in presenting your case. And that is with those cases that go to court.

It is almost impossible to use a previous win as any type of precedent for a different patient. Everyone's health situation is different, and the approval letters almost always contain weasel language about how it is a one-time exception for that specific patient and may not be used as precedent going forward. And I've already addressed the court issue . . .

So, your appeals are not taken through the legal system, but simply a settlement arrived at between LTH and the insurer?

By George I think she's got it ! Too bad you couldn't have asked someone or checked the web site earlier to understand this.

That further decreases the costs involved with an appeal.

And exactly how many appeals have you done to come to that conclusion (which, BTW, is wrong)?

No wonder you have those on your board with extensive employment histories in the insurance field.

The board has zero to do with any of my appeals. And their background in insurance does not involve health insurance appeals.

 

[LTHFAdvocate]

Sheri, sorry to hear about issues with your home and health. Hope all is back in good order and you have a Merry Christmas.

Thank you very much Tousi, we don't have to agree about everything to be kind to each other

Sheri

 

[Secretblend]

Never refrain from asking questions just because a select number of people don't like the answer. Your question has served to uncover some important truths.

Thanks for the postive response. However, I was joking when I said that.

Thanks to LTHFAdvocate for taking the time to answer our question. I know you are a very busy person and that means alot to me for taking your time to give us the facts. Sorry to hear about your house and surgury. Hope things go better for you in year 2008

Travis

 

[jillio]

Too bad you didn't have the common courtesy to contact me before you started spouting off "facts" about a foundation that you clearly know very little about.
Why exactly, would it have been commom courtesy to contact you, specifically. This has absolutely nothing to do with you personally, but with the foundation for whom you work.


Large administrative bonus? I hope you can hear me laughing all the way from California. If such a thing did happen, which it hasn't, it would be reported on the Foundation's 990 tax filing, which is publicly available on Guidestar. You won't find anything like that there, because, hmmm, it doesn't exist. And is that definition of a non-profit you provided another one of your "facts"? If so, the IRS would differ with you, their definition (which I'm pretty sure IS a fact) is at Exemption Requirements


There is a diffference between charitable and non-profit.


Last time I checked, when you increase the amount of an activity that you do that is causing you to lose money, it increases your loss, it doesn't decrease it.

When you increase the services connected to those which you claim to be taking a loss on, you also off set the loss.
Right, that explains why it took over 100 cases against Blue Cross before they changed their policy. You clearly haven't reviewed how our advocacy program works, or googled our Foundation. While we take what we consider to be a "legal" approach to our appeals, we have never filed litigation. Also, you keep on referring to legal representation, which our program specifically does NOT provide. We are insurance advocates.

Yes, I have googled your foundation. Infact, much of what I posted was taken directly from your website.

And you continue to get it wrong. I have already stated, and you either don't understand or continue to ignore, the fact that the facility where the surgery done is responsible for the purchase and billing for the implant, not the medical clinic or implant center. In this regard, CIs are no different than pacemakers, hip replacements, or any other surgically implanted prosthetic. On rare occasions and only at universities, the surgery facility might be the same business entity as the implant center, but the vast majority of the time there is no connection either financial or otherwise between the surgery facility and the implant center.

I am not ignoring that at all. In fact, I have stated it numerous times. And it is still falls under insurance coverage. Referrals can very well be considered a financial connection, as the patient base is drawn from referrals. Likewise, if your clinic physicians have surgical priviledges at any specific hospital, and perform their surgical procedures there, that is another financial connection.


I'm so glad I have you to interpret for everyone the reasons in MY mind behind why I do the things I do. This statement is wrong. Enough said.

And why exactly, is it wrong?

That's amusing. Have you ever actually LOOKED at an EOB for payment for cochlear implant surgery? The average amount paid across the US by insurers is about 31 %, not 80 %. And when you take the device out of the equation, because the surgeon and the clinic do NOT bill for or get paid for the device, the amount works out to about $2000 , which is just slightly (95 %) below your $40,000 "fact". And payments are always made to patients when the insurer is not contracted with the clinic.

That's average. And at 31%, we are still talking $15,500. Times how many surgeries per year?



We don't charge for training, and when people can't afford our clinic services, we give them away for free. Hardly the approach of someone trying to profit off of other activities associated with CIs.

What treaining is it that you don't charge for? You receive no remumeration at all for physician traning?



Must have missed that somewhere amongst your 54 posts in this thread, sorry. #1, we've never litigated a case ever, so you asked the wrong question. What you meant to ask is what is the ratio of HA appeals to CI appeals. CIs currently represent about 2/3 of our cases, which means we've done several hundred non-CI cases. This ratio is actually dropping pretty rapidly since we've been able to get over half of the insurers in the US to cover bilateral cochlear implants without appeals, we are doing more and more non-CI appeals every day because we are doing fewer CI appeals.
[/COLOR]

So, you don't litigate, you simply mediate. That explains board members who have extensive experience in the insurance field. More lucrative to use the experience on the outside than on the inside.

If they are paying for more implants without mediation, that decreases the cost you are spending on mediation, doesn't it? Like I said, precedence. And how many HAs have you gotten covered? I thought you said that you are not doing HA appeals for adults at this time due to workload and lack of funding. Which is it....are they increasing or decreasing?



Actually, I'm not being paid to provide legal representation at all -- see my comments above.

But you are being paid to provide mediation services. Either way, you are being paid by the foundation. No entity, whether non-profit or for-profit retains employees whose services do not provide a benefit to the organization.


Yes, *A* clinic and *A* physician might receive financial compensation when we win a case. But 97 % of the time, it is not a clinic associated with either CEI or LTHF. The 3 % of the time that a CEI physician benefits, CEI pays the Foundation for the costs of the appeal. CEI physicians are the only physicians in the country who have to pay the foundation for an appeal, how's that for irony?

Just keeping the money in-house.



I have never personally received compensation for doing an appeal in the eleven years I've been doing this. In fact, for the first seven years, I didn't even receive a salary. I am not on a retainer, my salary is not based on how many appeals we accept. And I've already said that the appeal never results in insurance payments to the clinic. Yes I get a salary (now), which is below market that I work very hard for. That doesn't introduce anything that suddenly invalidates the benefits of the appeals program.

If you are receiving a salary you are receiving personal compensation. But insurance payment does result in payment to the doctors performing the surgery that are connected directly to the clinic. No one has attempted to invalidate the benefits of the appeals program, but simply to point out that those involved in the appeals process are simply being paid to do a job that is secured through the promotion of CI surgery.



It is almost impossible to use a previous win as any type of precedent for a different patient. Everyone's health situation is different, and the approval letters almost always contain weasel language about how it is a one-time exception for that specific patient and may not be used as precedent going forward. And I've already addressed the court issue . . .

Almost is not virtually. And if appeals are continually lost, a cumulative effect is established. If that were not so, continual appeals would not result in policy change.


By George I think she's got it ! Too bad you couldn't have asked someone or checked the web site earlier to understand this.

As I said, I have checked the website, and much of what I have posted has come directly from that website.



And exactly how many appeals have you done to come to that conclusion (which, BTW, is wrong)?

I have done no CI appeals, but I have mediated for coverage previously denied in other medical fields. I completely agee with your stance that an insurance company has no business determining the neccessity of any medical procedure. What exactly does that have to do with the fact that your mediation promotes a devise that is implanted by surgeons connected to your clinic, and at least one of which sits on the boards of several CI manufacturers? Or that you receive remuneration for your mediation services?



The board has zero to do with any of my appeals. And their background in insurance does not involve health insurance appeals.[/QUOTE]

Perhaps they don't engage directly in the appeals process, but I find it difficult to believe that they don't act in an advisory capacity. Why else would their associations with the insurance industry be a benefit to their employment with your organization?

I'm still waiting on the ratios of HA appeals to CI appeals. 2/3 is not a ratio.

 

[shel90]

Shel I wore HA's for years, I never really liked what I got from them. When I got implanted I was only a profound/severe loss and scored to much in the quite booth. But life had gotten to the point where itreally sucked and the new aides I had purchased a year previously also sucked. I really like the CI compared to the aides. The clarity is amazing.

I doubt very much that people who only have mild/mod losses will be getting implants very soon (unless it's the implantable HA's they're working on now). And the reason they wouldn't be getting CI's is because they can do ok with the Ha's. (I think that's to bad that there isn't something better for them but many seem to do quite well with HA's...unlike me. LOL)

I always purchased my aides, and aides for my 2 daughters. We lost some and I'd have to replace them. With the kids my dispenser sold them for 1/2 of what I'd have to pay for them. He did much business with seniors so was limited to what was approved by the gov. and how much they would reimburse for them. So my guess is I got to pay more to make up for the lower cost sales....oh well such is life.

Thanks for sharing your experience and I respect that but the question was directed to Cloggy in response to his comments about HAs. I know the CI is better than HAs for some people.

 

[deafdyke]

Their advocacy results in doctors and hospitals being paid.

Agreed!!!! I sometimes think that if it weren't for oral only having such a HUGE profit factor (eg dependancy on oral schools, speech therapists, hearing aids and CIs) it wouldn't even be promoted so much.
Sheri seems to be kind of naive about that. She seems to take the slogan of AG Bell to heart (freedom in listening and talking) Oral only does not create freedom....it simply creates a dependancy on expensive healthcare (and in these times when even people without chronic issues have problems with high health care costs, that is NOT a good thing at all!)
I'm also kind of ambigious about the role of LTHF. It's a good organization, and Sheri does do work with other issues like atresia and microtia repair.....HOWEVER, just b/c a organization claims to be nonprofit or charitiable, it doesn't nessarily mean that it IS. Like everyone thinks that the Jerry Lewis Muscular Dystrophy telethon is non profit etc....yet there's hints of not exactly good stuff about it out there.
I think sheri also doesn't understand that if oral only didn't exist, this organization wouldn't even be needed, b/c kids could function 100% WITHOUT things like HAs or CIs or whatever.

 

[jillio]

I have figures. Shall I post them?

 

[shel90]

A question for Sheri

Sheri...my insurance wont cover digital hearing aides. Will LTH foundation help me fight my insurance company to get coverage for new HAs? It would be great if they can. I am going to contact LTH about it.

I am confused with all the points made by you and Jillo about financial incentive but I do agree with Jag...whatever motivation a foundation has, as long as they dont discriminate against anyone, it shouldnt really matter. That's my opinion.

I keep reading from this thread and different threads that the CI centers dont make profits from the surgery. How are they losing money? Cuz of the high insurance preminums they have to pay?

 

[LTHFAdvocate]

So, you don't litigate, you simply mediate.

Nope, that's not it. We prepare cases for potential litigation by exhausting administrative options ahead of filing a law suit, which BTW, is required under law. We are good enough at it that we haven't had to litigate yet. That is not mediation. Mediation has a very specific definition and context within the hierarchy of legal proceedings. No where in our web site does it say we provide mediation services. We provide insurance advocacy services. It would be nice if you got that right.

That explains board members who have extensive experience in the insurance field. More lucrative to use the experience on the outside than on the inside.

How do you come up with these statements without a shred of evidence to back it up? Every board member with insurance experience started on the board before the advocacy program existed. I see them all a grand total of twice a year for about 30 minutes each time, and one of those times is at a fundraising dinner. They play no role in either the strategy or day to day operations of the advocacy program or in any of the individual appeals.

I thought you said that you are not doing HA appeals for adults at this time due to workload and lack of funding. Which is it....are they increasing or decreasing?

The HA appeals we are doing are increasing, despite the fact that we are not accepting new cases for HA appeals for adults right now. As the work of the foundation gets more widely known, the number of parents applying to our program for help with HAs and services for children who don't have CIs has increased drastically. We take as many cases as we can. We do not prioritize CI cases over HA cases, everyone gets reviewed in chronological order of application date. We do prioritize children's cases over adult cases, and I've been repeatedly yelled at for that, and I own the blame for that because that was my decision, and my decision alone.

But you are being paid to provide mediation services. Either way, you are being paid by the foundation. No entity, whether non-profit or for-profit retains employees whose services do not provide a benefit to the organization.

OK, so using your logic, the teacher being paid by the state to educate my child in a public school is being paid to promote education? That makes no sense.

Just keeping the money in-house.

This comment makes no sense whatsoever. What money? Where? The Foundation isn't making money and neither are the doctors. The only organization that makes money when a CI surgery takes place is the implant manufacturer, which I have no connection to, financially or otherwise.

I am an employee of the foundation. One of a very large list of things that I do is appeals. I am not being paid to do a job that is secured through the promotion of CI surgery.

It is almost impossible to use a previous win as any type of precedent for a different patient. Everyone's health situation is different, and the approval letters almost always contain weasel language about how it is a one-time exception for that specific patient and may not be used as precedent going forward. And I've already addressed the court issue . . .

Almost is not virtually. And if appeals are continually lost, a cumulative effect is established. If that were not so, continual appeals would not result in policy change.

Just because I've left the door open (because I make sure I don't overstate the truth) doesn't mean you can drive a truck through it. There are many cases that have required 4 or more levels of appeals before we win. If losses created a cumulative affect, we would never win after losing three times previously on a case. Out of 1000 cases, I can count on one hand the number of times I have have been able to successfully use one approval as legal precedent to leverage another approval. Under federal law, the approvals are only precedent if the two parties in question (i.e. the approved person and the person asking to be approved for the same thing) are covered by the exact same plan, which means they both have to be employed by the same company, which rarely happens.

The reason our appeals eventually result in policy change is because the only thing insurers give a damn about is money -- they eventually get tired of spending thousands of dollars defending denials that they aren't going to win in the end. I estimate that each denial that an insurer takes through 3 levels of appeals costs them at least $6000 to defend in internal administration costs and outside opinions. After 100 or so of these, even companies like Blue Cross get the message.

I have done no CI appeals, but I have mediated for coverage previously denied in other medical fields. I completely agee with your stance that an insurance company has no business determining the neccessity of any medical procedure. What exactly does that have to do with the fact that your mediation promotes a devise that is implanted by surgeons connected to your clinic, and at least one of which sits on the boards of several CI manufacturers? Or that you receive remuneration for your mediation services?

Asked and answered repeatedly, and you have chosen to ignore the answer because you don't like it. And sitting on a surgeons advisory board is not the same as sitting on a board of directors. And if you had recently read any insurance denial letter in detail, you would know that there is always language in there saying that the insurance company is not making a determination of whether or not the particular treatment they are denying is medically necessary, they are making a determination of whether or not the treatment being requested is a benefit covered the plan. Insurance companies are not allowed to practice medicine.

Perhaps they don't engage directly in the appeals process, but I find it difficult to believe that they don't act in an advisory capacity. Why else would their associations with the insurance industry be a benefit to their employment with your organization?

I don't personally find our boards associations with the insurance industry to be a benefit. I'm so detached from the board, I honestly didn't even know about 3 of those until you posted it !. BTW, they aren't employees, they are board members. Big difference.

I'm still waiting on the ratios of HA appeals to CI appeals. 2/3 is not a ratio.

Actually, 2/3 is a perfectly valid ratio. But, I'll do the math for you its about 66.67 %, but shifting away from cochlear implants and towards non-CI related appeals. And before you even raise it, I will state that CI appeals are much easier than HA appeals, and yes, we deliberately decided to start with CI appeals.

When someone gets turned down for a HA, there are frequently other options for them -- there are many charities that help fund hearing aids, there is vocational rehabilitation, there are IEP/IFSP options, they can be financed or put on a credit card and paid off over time. Very few people can pull out a checkbook and write a check for CI surgery, and when someone qualifies for CI surgery, they are not receiving sufficient benefit from HAs by definition. Also, the ADA has good language in it that helps us with CI exclusions which we can't use for HAs. So we started there. Clearly we are not stopping there. There is only so much one little non-profit can do, and under the circumstances, I think we are doing quite well.

 

[LTHFAdvocate]

I have figures. Shall I post them?

Absolutely, but only if you can provide verifiable evidence of WHERE the figures came from and WHEN the figures were generated for data validation purposes, otherwise they are useless. I suspect based on the absolute lack of knowledge you have exhibited regarding how CIs are billed and reimbursement averages that I likely won't agree with them.

 

[LTHFAdvocate]

Insurance, rent, administrative staff, and medical support staff all cost huge amounts of money. When insurers reimburses $36 per clinic hour for an audiologist (which is the amount reimbursed for some hearing impairment related services), you are all but guaranteed to lose money, especially in California.

I keep reading from this thread and different threads that the CI centers dont make profits from the surgery. How are they losing money? Cuz of the high insurance preminums they have to pay?

 

[LTHFAdvocate]

If you have a written denial, or can send us a copy of the page from your plan saying there is no coverage, you can submit an application.

Sheri

Sheri...my insurance wont cover digital hearing aides. Will LTH foundation help me fight my insurance company to get coverage for new HAs? It would be great if they can. I am going to contact LTH about it.

I am confused with all the points made by you and Jillo about financial incentive but I do agree with Jag...whatever motivation a foundation has, as long as they dont discriminate against anyone, it shouldnt really matter. That's my opinion.

I keep reading from this thread and different threads that the CI centers dont make profits from the surgery. How are they losing money? Cuz of the high insurance preminums they have to pay?