| Michael Kaufman |
January 13, 2000 |
I don’t expect any action from this letter. I don’t expect any of you to even read it to the end. I doubt if any
of you have the humanity left in you to do so. Because of that, I’m not going to go into a lot of detail, but if
you need a refresher, it’s on my web site, especially my final response (unacknowledged) to your final review.
Mr. Kaufman, I haven’t written to you before, because you hired other people to take care of their respective job
positions in a professional manner, with integrity. A lot of time and a lot of communication has been expended
to make that happen.
Mr. Kaufman, at one time, my hope was piqued when you rededicated MRG’s integrity and ethics; when you stated that any executive or manager that caused harm to an employee, or had knowledge of that harm and did nothing, would be instantly dismissed.
Since January, 1996 I have experienced physical, mental and financial harm. I have followed the correct form for submission of claims and appeal of denials. I have kept my supervisors and managers informed, and supplied with appropriate documentation. Intracorp certified my short-term disability, The Hartford certified my long-term disability, the Social Security Administration granted my permanent disability. Yet, if any of the other addressees to this letter had really done their job, there would have been no disability.
As I said, I no longer expect any action from this letter. It is more for my benefit, a catharsis. I’ve gone through all the stages of grief, especially hate, now I must grasp and maintain acceptance. I’ve come to accept the pettiness, the narrowness, the closed mindset of the corporate whore.
It’s all about money. I won’t bore you with the details and facts. Don’t bother to ask Linda Farina, she’s studiously ignored them. She’s used the "reliance of others" clause to a fault; what is usually called passing the buck.
Bill Watson failed to acknowledge any communications. Beneath him I guess.
Lucy Finger followed the script, which doesn’t include acknowledging "the rest of the story."
Bill Thurlow still owes me an apology; I’ve had disinterested professionals look over the "counseling" documents and the project documentation; my version is correct. ADA should have been invoked a long time ago. The best argument against Christianity is Christians.
Keenan Wright: it hasn’t killed me, YET. I do have a lawyer, I don’t have the money, YET. I wasn’t recording, were you?
Back to the money. I see First Health is trying to confuse the issue once again with another name change. Be that as it may, no matter how many name changes, no matter how many times you ignore my requests for the name of the First Health Medical Director and the name(s) of the consulting physician reviewer(s), they are eventually obtainable.
While I’ll have to go to Federal Court for the ERISA part of your actions, there are still some civil remedies against the consultant or consultants, their employers and all associated individuals for personal harm. I have been informed that their actions will not be protected by their malpractice insurance as I have made available to them a multitude of citations from the medical literature in support of the need for my treatments. Any contradictions or lack of consensus in citations becomes merely a difference of opinion. Any person or persons that caused that information to be withheld in the form of incomplete files and/or charts may also be party to the action. Any that have ignored the accepted medical literature in order to perpetrate a fraudulent assessment of my medical condition for their own financial gain or to assist the gain of others may also be party to the action.
The whole thing was a sham from the start. The EOBs impart no meaningful information, by design. Denial codes do not follow the language of the Plan, by design. When anybody requests (as I did) explanatory information, you label it an appeal. Nope, since the EOB didn’t comply, the stopwatch can’t start. That’s o.k., that will come out in court.
I’ve pointed out in every one of my letters (this one is no exception) what the Plan defines as "medical necessity", and how the First Health EOBs fail to satisfy notification requirements when an adverse decision is made. Every time, you ignore it (did ya’ ever notice that ignore is the root word in ignorant).
"shall provide to every claimant who is denied a claim for benefits written notice setting forth in a manner calculated to be understood by the claimant:
(1) The specific reason or reasons for the denial;
(2) Specific reference to pertinent plan provisions on which the denial is based;
(3) A description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary and;
(4) Appropriate information as to the steps to be taken if the participant or beneficiary wishes to submit his or her claim for review."
29 C.F.R. @ 2560.503-1(f).
"OO. Medically Necessary means a medical procedure or supply that satisfies all of the following:
(1) It must be legal;
(2) It must be ordered by a Physician;
(3) It must be safe and effective in treating the condition for which it is ordered;
(4) It must be part of a course of treatment which is generally accepted by the American medical Community, including all branches of professional societies and governmental agencies;
(5) It must be of the proper quantity, frequency and duration for treatment of the condition for which it is ordered.
(6) It must not be redundant when it is combined with other services and supplies that are used to treat the condition for which it is ordered;
(7) It must not be Experimental/Investigative;
(8) It must not be maintenance therapy or treatment; and
(9) Its purpose must be to restore health and extend life."
So it came down to, you would pay for (once) 2G of Rocephin IM (and associated charges), but not two 1G of Rocephin IM (and associated charges) because you found unnamed "reviewers" that would say it wasn’t sufficient to eradicate. If you had been reading what I had been sending, you would have found that:
BTW – Twice I pointed out that the First Health documentation in support of denial stated "2mg". Since the 1G you allowed them to deny is greater than their 2mg, it is ludicrous in the extreme to allow a denial to stand.
But of course, you didn’t bother to read that stuff. You have others to pass the buck to. Excuse me, "reliance of others." If you had bothered to read it, you could have figured out for yourself that what the FHMD and the consultants wrote didn’t make sense, and was totally insupportable. Funny, once you put them under contract, and they don’t have to worry about the wellbeing of the patient, they can overlook the statement "The recommended dosages and durations is a minimum or average, and should not be construed as absolute" in the text they are supposedly using to substantiate their ludicrous "not sufficient" claim. Also, was it just happenstance that the reviewer (Dr. Greenhood) was terminated following my record review, or was it retribution for overturning some of the First Health Medical Director denials?
Every prudent physician, when confronted with a patient experiencing an adverse treatment reaction, in this case a Herx, has few options beyond providing NSAIDs, halting the treatment, or adjusting medication dosage and frequency based on patient tolerance. From my web site and information I’ve sent you and First Health in the past:
Timing, Frequency and Duration:
This is individualistic and Herxheimer can occur within days to weeks after the onset of antibiotic therapy. In some patients they occur only once or twice (if at all) and with others continue throughout the course of treatment, usually lessening in severity. They can occur and are more often described in cycles (example: every 4 weeks) and have been reported to last from days to weeks.
It can be very beneficial to document these exacerbations. Some physicians use this as a guideline for treatment. Further it may help differentiate herxheimers from the normal symptoms or progression of Lyme disease.
Have any of you ever had a Jarisch-Herximer reaction? It’s a phenomenon that causes the symptomology to appear to worsen. It was first noticed in syphilis patients, which is also a spirochetal illness. The Herx is the bodies immune response to the endotoxins released during spirochete killoff, such as increased joint or muscle pain, headaches, chills, fever (usually low grade), drop in blood pressure, hives and rash. If you’ve been undergoing neurological or cognitive problems (late-stage Lyme), all bets are off.
I’ve spent my 14+ years in Uncle Sam’s Green Machine, visiting far-off foreign climes, making the world safe for democracy, concussed by mortar and rocket barrages, pulled off blood sucking leeches, even experienced the soft-tissue impact of copper-clad projectiles. I’d take that again over what I experienced with that one 2G Rocephin IM.
Bill, Keenan, you wonder about my personality change, why I became so hard to deal with? Try dealing with a wife that had been going though just that (my kinda Herx) for the previous two years (you were very understanding and flexible there), going crazy fighting off those effects in myself, and trying to deal with First Health/Linda Farina. On one hand trying to get well, on the other hand, trying to work for a company doing its best to keep you from getting well. All over whether to pay $150 for one shot, or $75 for a shot today, and $75 for another shot in three days. And she can’t figure it out? Or doesn’t want to figure it out? Do I really want to work here? When that is a Senior Director?
I had asked for your assistance in tracking any behavioral changes, provided you with documentation outlining the progression of the disease. Karen sent a patient advocate letter pleading for help. Dr. Moayad sent a letter requesting authorization for the most aggressive treatment. All documentation outlined the inevitable outcome without appropriate intervention. Did anyone intervene? Did anyone use their discretionary authority? Nope, the plan to get rid of me started instead. "He wasn't terminated or discriminated against for exercising his rights under ERISA, he just wasn't performing to expected level." So very transparent. I just didn’t have the energy, maybe even the desire, to fight. I mean, if it’s more important to make Carol Pfingston feel good about herself than to get $2,000,000 into the bank on time, what kind of company is it, really?
Linda, you are very good at your job, but you don’t want to know a thing outside your narrow little world. It’s one thing to know what form to fill out, who to call in what circumstance; it’s another thing to know when to step in and actually use the discretionary authority of your office. The English language is very good for con men and crooks. Bill is quite aware (and perturbed) that I call them weasel-words. I’m quite sure that First Health could find even more "not medically necessary" reasons with very little effort. Most would not stand up under scrutiny. Given a fair hearing (not the stacked deck you’ve attempted to hand me), none of the medical necessity denials used in my case stand up.
So what’s the real problem? It’s still money. You’ve let the denial stuff build up so much, I’m in arrearage to my doctor so much, that I can’t get treatment to get better.
Believe it or not, the money paid out in disability is more than what the medical arrearage amounts to. Penny wise, pound foolish, but you dug yourself in too deep with fallacious denials to admit you are wrong. All in all, I’d rather be working and a tax-payer, not a tax-eater. But, as long is it doesn’t come from your budget center, it’s not your problem?
Mr. Kaufman, did you really say "when you treat Lyme, you tend to see Lyme everywhere"? That’s about as insensitive as "just a housewife" or "hysterical female." Dismissing something with a derisive comment does not make it go away. It’s existence is still real, whether you want to deal with it or not. Because of the strict reporting requirements (not all cases of Lyme are reportable), the CDC estimates that only 10% of all cases are reported to them, yet there has been a >30% increase in reported cases. You might be seeing it everywhere because it is everywhere. Try this experiment. Put a sign on your car window for a week that says "HONK if you or someone you know has LYME" and keep count. There were only 57 cases reported in Texas last year. Now either everybody knows those 57, or they aren’t all getting reported.
There is no doubt of my Lyme diagnosis. Besides isolating and culturing Bb, positive IgM and IgG Western Blot, positive ELISA, 26 of 30 clinical signs, meeting the strict CDC reporting standards; there is also a second confirmatory opinion based on the latest sophisticated testing methodologies, performed by one of the most respected physicians this country has.
It should also be noted that the Social Security Administration approved my disability on the first application, which is almost unheard of. It took over two and one-half years, nine-denials and an administrative court hearing for my wife to obtain her SSDI.
If my physician had been left free to follow his treatment plan and not fighting False Hope, I’d be working, not disabled. All because of Linda Farina, and none of the others turned her in.
So, in summary:
Ms. Linda Farina, acting in her capacity as the named fiduciary for the Metromedia Restaurant Group employee benefit plan, has allowed, through her own action or inaction, the following to occur:
1. For Karen J. Rose, as beneficiary of her spouse’s MRG employee benefit plan, Ms. Farina has failed to act upon outstanding claims for 1995. Despite repeated written and verbal requests, outstanding claims for 1995 have not been released for processing.
a. During 1995, Karen was an enrollee of the LabCorp employee benefit plan; as such, any claim to the MRG plan for 1995 falls under the "coordination of benefits" clause. Under this clause, MRG’s liability extends only to the plan benefit allowed amount normally paid by MRG, minus any reimbursement by other plans.
b. As an example, if a procedure or supply claim is submitted for $3.00, and the LabCorp’s plan benefit allowed amount is $1.00, and the MRG plan benefit allowed amount is $2.00, then MRG has the obligation to pay 80% of the $1.00 difference in the plans. Where MRG’s plan benefit allowed amount is larger than the LabCorp benefit plan allowed amount, 80% of the difference is due and payable. Where MRG’s benefit plan allowed amount is equal to, or less than, the LabCorp benefit plan allowed amount, no adjustment is forthcoming.
c. Approximately 75% of the 1995 claims have been processed using the "coordination of benefits" clause, with reimbursement due and paid on a significant portion, although in insignificant amounts. The 25% of claims that has been the subject of so many letters, faxes, e-mails, and phone calls, still have not been released for processing. Only when the claims are released and processed will anyone know whether LabCorp or MRG has the higher plan benefit amount.
2. For Karen J. Rose, as beneficiary of her spouse’s employee benefit plan, Ms. Farina has failed to act upon all claims submitted from June 1, 1998 to date. On June 1, 1998, MRG became the primary employee benefit plan for Karen. The "official" explanation is that First Health Strategies, acting as Third Party Administrator for the MRG employee benefit plan, is waiting for requested medical information. This "explanation" is invalid, given that the medical record information requested has been sent multiple times, return receipt requested (returned and filed).
3. For R. James Martin, an enrollee of the MRG employee benefit plan, during an appeal for denial of claims for 1996 and 1997, did not provide the independent medical reviewer with the complete administrative record. Further, she allowed additional documents not part of the administrative record at the time of review to be introduced. The appeal reversed some denials, and upheld some denials. It is felt that the contents of the administrative record would have reversed all denials on appeal; it was only the introduction of additional materials that provided the basis for upholding the denial. Of note, the independent medical reviewer was terminated one month following the review.
4. For R. James Martin, an enrollee of the MRG employee benefit plan; with the exception of claims 927816390024 and 927816390014, Ms. Farina has failed to act upon all claims for 1998 and 1999. The "official explanation" is that First Health Strategies, acting as Third Party Administrator for the MRG employee benefit plan, is waiting for requested medical information. This "explanation" is invalid, given that the medical record information requested has been sent multiple times, return receipt requested (returned and filed).
I am receiving long-term disability from a policy purchased through MRG, and receiving Social Security Disability Insurance.
My case prognosis is poor, with the following diagnosis:
| Lyme Disease | Memory Loss | Immunodeficiency with Lukopenia |
| Lyme Arthritis | Depression, Secondary | Spasticity |
| Lyme Meningoencephalitis | Anxiety | Hypertension, Moderate |
| Optic Neuritis | Panic Disorder | Bilateral Maxillary and Ethmoid Sinusitis |
| Cognitive Dysfunction | Facial Palsy | Cerebral Cortical Atrophy |
| Chronic DVT | Protein-C Clotting Disorder |
R. James Martin
501 Sycamore Lane, #327
Euless, TX 76039
This letter to become a web page in 10 days.
