Linda Farina

October 22, 1999

Senior Director, Benefits & Compensation
Metromedia Restaurant Group
6500 International Parkway
Plano, Texas 75093

Ms. Farina:

On May 31, 1998, my COBRA benefits with Lab Corp (including my 10-month coverage extension due to Social Security Disability) expired. On June 1, 1998, First Health became my primary health benefits plan payor. Since that date, not one claim filed with First Health has been processed, much less reimbursed.

As we anticipated, First Health began using their customary tactics to delay processing of my claims. From June 1998 through December 1998, they asked me to provide EOBs from my primary payor, even though they had prior notification from Lab Corp as to the end-date of my primary coverage. After re-notifying them of this end date, the requests for information started appearing, and continue to this date.

Dr. Moayad has complied multiple times with the requested information, beginning in August 1998. As we have experienced before, they say they don’t have the information and asked him to resubmit. These obvious delay tactics can no longer be tolerated. Information has been duplicated 3 times via certified mail/return receipt requested. We have the receipts verifying delivery, yet they say they cannot verify the signature and claim to not have the "requested" information. (This same tactic has, and continues to be, used with James’ claims as well for all treatment dates not included in the appealed/denied package.)

We should not have to suffer because of their unethical business procedures and obvious incompetence. Our physician also should not have to suffer economic losses for their failure to reimburse meritorious claims in a timely manner. The additional time required by the office staff to reprocess mountains of information is expensive and decreases time that should be more effectively utilized in treating patients. Our physician (an internationally renowned Lyme Disease specialist and researcher) has/had 18 patients whose "health benefits" are administered by First Health. Imagine the costs of these delay tactics being duplicated by this number.

First Health should be quite familiar with my case; my diagnosis, my prognosis, and my treatment regime. After all, they have been paying (as secondary, "coordination of benefits" payor) since April 1995. Timely payment has been forthcoming from February 1996 through May 1998 (again, as secondary, "coordination of benefits" payor). I have not encountered any treatment denials – YET. The current lack of claims processing is blocking my access to Medicare (my secondary payor) reimbursement.

The reason behind these information requests is painfully obvious. The only purpose served is to delay, delay, delay payment to save their client (MRG) money. What possible use could information that is 3 years and 3 months old serve? They can track my treatment through their own EOBs. All the information they are "requesting" is contained in these EOBs. (However, this information could serve to educate First Health’s consultants on the benefits derived from administering the proper treatment protocols.)

We are quite well acquainted with the lengths self-funded health-benefits plans like MRG and Lab Corp will go to protect their profit margins. With Lab Corp, I suffered no treatment denials or delays in payment. However, Lab Corp did try to defraud me of coverage under COBRA claiming I could not have COBRA coverage because I had other insurance. They even provided me with a distorted version of the law covering COBRA eligibility.

It took 18 months to correct their error. During this time, NONE of my providers were paid. After being provided with the actual wording of the statute regarding COBRA conversions (by the U.S. Department of Labor), my benefits were reinstated and my claims were paid. Additionally, Lab Corp was required to extend my benefits another 10 months because of my disability status under Social Security.

The reasons for these abuses of discretion are directly connected to the high cost of treatment for chronic Lyme Disease – an incurable disease that is the 2nd fastest growing epidemic worldwide, and is the fastest growing disabling disease. We do not die as fast as AIDs patients. With cancer, you’re cured or you die. Lyme patients get progressively worse (especially without access to the appropriate aggressive treatment protocols) since the spirochete is capable of invading every body system and can be extremely resistant to current antibiotics. We live long, ever-debilitating lives, and health costs can only increase. The discrimination against us and other costly chronic illnesses is the reason we have a health care reform crisis currently under Congressional review. Companies like MRG and Lab Corp try to hide behind their so-called ERISA shields, and hope patients will give up. We won’t, although most people do.

Texas, thankfully, was the first state to pass a patients bill of rights because of the increase in companies who wrongfully deny their employee’s necessary medical care as promised upon hiring.

These tactics, and others as onerous, have many doctors closing their doors to Lyme Disease patients because of the aggressive discrimination leveled against their practices by insurance companies and TPAs. (Insurance companies are less likely to take such extreme measures as companies like First Health and USHealthcare.) It also leaves us living in fear of losing access to the minimum standard of care required for all Lyme Disease patients.

In summary:

• All claims submitted to FIRST HEALTH covering the period of June 1998 through this date have not been processed or paid. Their system has them listed as pending, awaiting requested information.

• The requested information to release the pended status has been resubmitted 3 times, with certified proof of delivery.

Your assistance in expediting a resolution is needed.

 

Sincerely,

 

Karen J. Rose