Resolve Issues with Your Health Plan

Once upon a time I submitted a routine claim to my health plan and it was sent back, marked "Denied." After a moment of dismay I called the plan's customer service department and found that the problem was clerical. With a few minor adjustments to the way the form was filled out, the claim went through.

The moral of this story: Don't just lie down and take whatever your health plan dishes out to you. There are many avenues for resolving your financial as well as medical issues.

Know Your Rights and Your Coverage

In New York State, the Insurance Commission plainly states on its Website: "As a consumer in New York State, you have the right to obtain basic information about your plan, to receive quality care and appeal denials of service and claims, and to have your claims paid in a timely manner."

Every state has an insurance commission. All can be found through the Website of the Health Insurance Association of America. One mission of these state insurance departments is to mediate between insurance companies and individuals. You can ask for an "external review" by neutral experts. That will take a month or so in New York, but the process can be expedited for urgent health issues.

External reviews cover a wide range of grievances, including specialists' fees charged beyond the standard co-pay, plans' failure to reimburse for expenses for services provided out-of-state and many other topics.

One word of warning: Your rights will not supersede what is covered under your health provider's contract.


Use the Internal Review System

What if you need to straighten out an issue, such as billing errors? The best first step is to use your plan's internal review system. Call the customer service or claims processing department. Be friendly but demanding. This is a good place to uncover processing mistakes and clerical errors.

In my case, an error involved a bill from a doctor who had left my plan shortly before providing a service. His office had taken my $10 co-pay, then sent a bill for $550 as an outside provider. The doctor's billing service and my plan's reps said it had been my responsibility to ascertain whether he was on the plan before receiving the service.

For two years I sent back bills with letters explaining that I would not have seen this doctor if I had known he had left the plan. Billing departments sometimes have power to make decisions. I called the billing service several times, then finally was told they were eliminating the incorrect overdue balance.

Keep Good Records

As in any dispute with a many-layered bureaucracy, your attempts to resolve issues with your health care provider should be well documented. Write down the date and time of each conversation and the name of each person you speak with. Keep notes or recordings of all telephone conversations, as well as copies of all letters, bills, and claim forms sent and received.

The further your dispute goes, the more important that you've kept good records from the beginning. To prevent your credit from being marred because you've refused to pay a bill that is in dispute, send the complete records of the dispute to your credit bureau.


Enlist Outside Help

If you are not satisfied with the responses from your provider or state insurance commission, try getting your local elected officials involved. The Center for Patient Advocacy points out that when you talk to your congressperson or senator, you are giving them a first-hand look at the problems patients face within the managed care system. This may be of interest to them.

For medical issues, ask your doctor to explain to your HMO in writing why a disputed service is necessary.

If your insurance comes through your employer, then your employer may also be able to exert some pressure on the health care provider.

Review systems are geared toward avoiding lawsuits, which can be costly and time-consuming for both sides. If need be, however, consult a lawyer about the possibility of resolving your issue in court.

Don't Give Up

Be persistent! According to a study by the New York State Insurance Commission, in 1997 more than half of all "grievance determinations" were resolved in the consumer's favor.

Resolving Health Care Issues

  1. Use your plan's internal review system.
  2. Talk to the billing party as well as to your provider.
  3. Know your rights and coverage.
  4. Request an external review from your state's insurance commission.
  5. Keep paper records of all attempts to resolve your problem.
  6. Ask elected officials and other authorities for help if necessary.
  7. Be persistent.
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