You send out invoices and nothing happens. Chances are there is a mistake in the billing. Most insurers will make some payment for LYME DISEASE, even though they are not happy with it. However, if there is a mistake in the billing they will refuse payment and let you figure out why. If you have corrected all the mistakes, you will find that some insurers will pay for 2 weeks of treatment, or 4 weeks of treatment, and then they will stop paying. They will usually say that the treatment is not medically necessary. Their rationale will usually be that if the treatment did not work in 4 weeks then the additional treatments do not help the patient. In many occasions the patient may not have improved, or may have gotten worse. But the doctor, with some justification, will say that had the patient not been treated he or she would have gotten much worse. This state of events should not discourage your reimbursement people.

The reason the insurance companies feel secure in their position is because there are doctors who criticize treatment after 4 weeks. And, of course, insurance companies get the doctors to look at the file and give them that opinion. But those opinions are almost never based upon a personal examination of the patient. The opinion of the treating physician is entitled to great weight, in insurance and in medicare cases. (See Schisler v. Heckler, 787 F 2d 76, 81 (2d Cir. 1986); Klementowski v. Secretary, 801 Fed Sup 1022. These cases say that the treating physicians certificate of medical necessity is binding unless contradicted by substantial evidence.

If the case represents a clash between the insurance doctor and the treating doctor, the treating doctor will usually win out. However, that does not mean that the insurer will pay. The treating doctor should usually set forth in his certificate of medical necessity the reasons why this patient needs additional days of treatment, and what he thinks the additional days of treatment will accomplish. The more specific his certificate is the more likely the invoices will be paid. This is true even if the doctor's certificate is written retroactively. That is, if the doctor writes the certificate in December for treatment that occurred in June, it will be useful if the details he includes are based upon the patient's readings.

Nothing that we have set forth above will necessarily avoid bringing a lawsuit, if the insurer persists. But the increased documentation will be helpful in dealing with the insurer during litigation and settlement discussions.