Managing Your Health Care
Private Health Care Coverage Understanding Your Policy Tips on Fighting Back Appeals, Grievances, and Complaints Prescription Drugs Medigap and Long-Term Care Insurance Medical Billing Protecting Private Information Questions about COBRA and Continuation Coverage Government Programs and Assistance Glossary of Terms
Tips on Fighting Back
How to Get the Health Care You Need
Let’s say you have encountered a problem with your health plan. Maybe you can’t get a referral to a specialist. Maybe plan administrators are telling you that treatment is not “medically necessary” or is “experimental.” Or maybe they say that the treatment your health care provider recommends is not covered. Here are some general tips to help you navigate the health care maze:
1. Be a Squeaky Wheel
The adage that “the squeaky wheel gets the grease” holds true with your health carrier. By complaining to the health plan administrators, government officials, and your medical providers, you are more likely to get the attention you deserve.
2. Be Firm
Let the health plan know that you believe it is in breach of its promises to you. These are legal words that tell the health plan you mean business, you know your legal rights and will enforce them if necessary.
3. Read Your Contract
Don’t accept the health plan’s claim that something is not covered. Read your contract and determine for yourself if the health plan’s position is right or wrong. Compare the language in the health plan’s denial letter to the language in your contract.
4. Document Your Dealings
You can bet that when you call the health plan, they are taking notes on what you say. You should take notes, too. Get names and numbers and write down what you are being told. Then, if you need to refer back to a conversation, it’s there.
5. Put it in Writing
If you have a complaint against your health plan, put it in writing. This way it will be harder for the health plan to minimize your concerns.
6. Be Your Own Advocate
Ask a lot of questions and know your rights. Let the health plan know that you understand your rights.
7. Get Your Doctor to be Your Advocate
Develop a strong relationship with your doctor. When you encounter a problem with your health plan, ask your doctor to write a letter on your behalf disputing the denial with language from the contract whenever possible.
Your health plan has informal appeal and grievance processes. Try using these forums.
9. Find Out Who is Behind the “No”
In the case of a self-insured health plan, your employer might want to provide the coverage but maybe its stop loss carrier (which insures the employer) does not. Or maybe your physician wants to make a referral but the HMO is telling her she can’t. Find out who is really behind the refusal to let you have the care you need. It will make solving the problem easier.
10. Enlist an Ally
Enlist an ally such as a friend, family member, or a lawyer to assist you, especially if you are sick.
11. Go to the Top
If you don’t get the resolution you need from people lower in the organization, go straight to the top. If an employer’s self-insured plan is telling you “no,” get the President or CEO of your company to intervene. The big shots at the top may not even know that the administrator they employ is denying you coverage.
12. Get Treatment First
If you need treatment that a health plan won’t let you have, consider spending your own money to get the treatment. You can fight the health plan later to get reimbursed. If your health plan won’t let you see a specialist, consider finding one and making an appointment on your own, using your own money to go.