How Does Your Health Plan Measure Up?

It’s that time of year again--employers call it “open enrollment”--when many people are given a chance to select or switch health plans. Today, Health arms you with information, tips and resources to help you make the best choice for you and your family.

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Illness is never a pleasant experience.

But far more unpleasant is the moment when you find out that your medical insurance will not cover either a treatment that your doctor recommends or one that you believe you need.

No matter your health plan, there may come a time when you have to fight to get medical care. And the last thing you need to be doing when you are sick is fighting with your insurer or doctor.

For this emerging world of managed health care, you need a new set of operating instructions. This article is a quick guide to help you head off problems before they occur, and to help you get the medical care you need when disputes arise.

The recommendations here are ones on which health care experts across the spectrum of opinion--HMO representatives, consumer advocates, insurance regulators and others--generally agree.

The most important thing to keep in mind is that you are not alone. There are government officials, consumer groups and staff at your health plan who can help you maneuver through the bureaucracy.

Two rules to keep in mind from the start, according to many experts: Understand how your plan works and call for help if you think you have been unfairly denied care.

“Most insurers operate in a reputable fashion, but there are also insurers who have questionable claim denials,” said Kathleen Sebelius, the insurance commissioner of Kansas and chair of the health committee for the National Assn. of Insurance Commissioners.

“While we cannot make a company pay a claim, we typically can help expedite the process and help consumers figure out if the claim denial was legitimate,” she said.

New Mindset

For better or worse, for most of the past century patients went to doctors, did what the doctor told them to do, and insurers generally paid the bill. That set of relationships has changed drastically in California and elsewhere during the past 10 years.

Today, the doctor, the medical group and the health plan are tied together through financial arrangements and incentives to reduce the cost of care. Many considerations influence their decisions, including keeping the lid on costs, keeping profits at a certain level and making sure the patient gets the necessary treatment--neither more nor less.

With traditional insurance, the doctor was virtually free to order whatever tests or procedures deemed necessary, and the insurer paid as long as the service was covered by your policy. With managed care plans, your doctor often must get prior approval from the medical group or health plan before going ahead with certain treatments. If the insurer refuses to authorize a procedure, test or treatment and you still want it, you have to pay for it out-of-pocket. But the option of paying for medical care yourself is not realistic when it involves an expensive surgery or other costly test.

“All of a sudden there is someone out there saying, ‘No.’ It may be your doctor, your medical group, your health plan or your employer, who is no longer offering the same scope of benefits they were offering 10 years ago,” said Peter Lee, director of the consumer protection program at the Center For Health Care Rights, a Los Angeles patient advocacy group.

All this means that if you want to get the best possible medical care, you need to be an activist. That does not guarantee that you will get the result you want, but it will take you in the right direction.

“To make things go right, you have to take action,” said Susan Pisano, spokeswoman for the American Assn. of Health Plans, which represents roughly 1,000 managed care plans nationwide.

“You have to put time into advocating for yourself,” says Larry Leavitt, a senior health policy analyst at the Kaiser Family Foundation, a nonprofit health care group in Palo Alto.

And especially when things go wrong, it is crucial to take action. In a survey of 2,500 consumer complaints in Sacramento, roughly one in four people reported a serious problem with their health plan. Half of those people contacted their doctor or plan and got it resolved.

“But a third of people who had problems did nothing about them because they thought it wouldn’t do any good,” said Lee, whose organization helped with the study.

Before Disaster Strikes

If your car needed repairs, you would go to the garage with a list of problems: The engine is smoking; the brakes are soft and there’s a loud rattling noise. The mechanic would inspect the car, discuss the likely problems and recommend repairs.

You may spend more time thinking about that meeting with the mechanic than you do thinking about your health insurance or your most recent doctor’s visit.

Here are four things you can do to lessen the likelihood of a problem with your plan.

Know what your insurance policy covers.

It is likely to be in small print, but read your coverage contract, often referred to as “evidence of coverage.” Do not assume that all treatments are covered. For instance, under what circumstances does your plan cover psychotherapy? How about organ transplants?

“Hardly anyone reads their insurance contract, and it’s important to understand that health insurance, especially now, doesn’t cover everything,” said Leavitt.

“And your plan now may not cover a service that would improve your health,” he said.

Know the answers to frequently asked questions.

At which hospitals are emergency visits covered? What telephone number do you need to call on weekends or in the evenings to get emergency care authorized? Do you have a number at which your doctor can be reached on evenings or weekends?

Keep a list of those phone numbers in your wallet and next to a phone in your house.

Following the right procedure can save you hours of hassles over the phone and a lot of anxiety.

If you want to go to a specialist outside of your plan’s network of doctors, get approval first from your plan. When you see the specialist, bring whatever forms the insurer requires to process payment.

“Often people get things denied because they haven’t gone through the right hoops,” said Lee.

Bring a list of question when you visit the doctor.

Make sure you understand the doctor’s answers, the course of treatment he or she is proposing and what you are supposed to do next.

“People should not leave their doctor’s office without asking why the physician recommended a particular course of treatment, what other options there were and why they did not recommend those,” said Pisano.

This information can be crucial later if you decide to appeal a plan’s coverage decision. For example, your doctor may tell you that she is recommending a “second-best” treatment because your plan does not cover the treatment she thinks is right for you. That kind of information can be a signal that you need to consider making an appeal.

Keep a written record of your meeting with your doctor.

This may seem like a pain--and may irritate your doctor--but it will be essential if you decide to appeal your health plan’s decision. The goal is to have a paper trail that you, your doctor and your plan can use in reviewing treatment and coverage decisions.

Changing Your Health Plan’s Decision

Every health plan has some type of internal appeal, or grievance process, for resolving patients’ complaints. But some plans do a better job than others of explaining how to file an appeal and how the process works. The internal appeal is one in which a plan doctor or panel of doctors reviews your case and decides whether the medical care is necessary and covered by your policy.

If you are not satisfied with your plan’s grievance process, some states have independent appeals boards that have no connection to the plan. When you have exhausted your plan’s internal system you can take your case to the appeals board.

Do not hesitate.

If you think your doctor or plan is inappropriately denying a treatment, contest that decision immediately. Some plans require you to file an appeal within a certain time frame. Don’t miss that deadline.

Where exactly does the problem lie?

Is the test or procedure covered by your medical policy? Is it your doctor who is refusing to recommend the procedure, or is your medical group or health plan refusing to authorize it?

If it is the health plan or medical group’s decision, try to enlist your doctor as your advocate. Your doctor knows your case, and the doctor’s staff will likely have to spend a lot of time duplicating records and communicating with the health plan to resolve your complaint. Make allies of them. No matter who is responsible for the denial, make sure you get a written explanation of why the treatment is not covered by your policy.

“Make sure you understand the reason for the denial and get it in writing,” said Lee, adding that you should also ask what information is being relied on to justify the denial.

You need to know whether the plan or medical group saw a copy of your medical record or consulted a expert in your particular disease or medical condition. Are they basing the decision on a particular article in a medical journal?

Get help.

Regrettably, many problems that result in appeals occur when you are at your weakest, feeling sick and less likely to be thinking in a clear, analytic way about your situation.

Bring a family member or friend with you to the doctor to make sure you ask the right questions and get the information you need.

You may also seek help from a consumer advocate group or the appropriate state regulatory agency. In California, the regulatory responsibility is split between the Department of Corporations, which regulates HMOs, and the Department of Insurance, which oversees other health insurance entities.

Also consider talking to your employer or your company’s human resources department. Remember, your employer, who pays for the bulk of your medical coverage, is your health plan’s or medical group’s customer and wields more clout than you alone.

Follow the appeals rules.

Call your health plan and make sure you know how to appeal. Then, work with the information you have about your denial. Your goal is to present a clear and convincing case to your health plan or medical group for why you should get a specific treatment.

Consider getting a second opinion--perhaps from a doctor who specializes in your particular medical problem--and submitting a letter from that second doctor as part of the appeal. Some doctors may rethink their decisions if they know a colleague, especially one with more expertise in a specific area, reached a different conclusion.

Use the Internet to research your disease or call support groups in your area to find out what treatments are generally recommended for people with your health problem.

“A health plan is going to look at what other doctors say. They are not listening to a patient say, ‘I want this operation because my friend down the street got it,’ ” said Lee.

Write a specific appeal letter.

Do not say you want “appropriate care for breast cancer.” Say you want a specific treatment, state why the care is covered by your plan, include language from the coverage documents and give the medical support for the treatment you’re seeking.

Most important: Do not give up until you feel satisfied that you are getting the care you paid for. You may not always get the treatment you wanted, but at least your case will have received full consideration.

In health care, as in other matters in life, the squeaky wheel often gets the grease.

“It’s probably the case that a consumer can’t be too aggressive in dealing with their health plan,” Leavitt said.