Arm Yourself With Knowledge to Get the Care You Deserve
Not long ago, your family doctor decided the type of care you needed and made the necessary arrangements. Today, health care is much more complicated. While your primary doctor is responsible for overseeing your medical care and treatment, lots of others may also play a role. Other doctors, nurses and health professionals, as well as insurance companies, administrators and your employer may also have a say in the type of care you receive, where you get it and who provides it.
Surveys of consumers have confirmed again and again that people are having problems with their health care plans. We see these problems every day at the Center for Health Care Rights, a Los Angeles-based group that helps consumers with health care issues. People are confused about how to navigate a complex system, how to get appropriate care, what to do about disputes over coverage and why they can’t see the doctor they want to see.
Unfortunately, many of those problems never get resolved. A statewide survey in 1997 found that 43% of people who had a problem with their health plan did nothing about it. A separate survey of Sacramento-area consumers in 1997 found two main reasons why people did nothing to resolve problems with their health plans: (1) They didn’t know where to turn for help, and (2) they didn’t think trying to resolve the problems would do any good.
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The first step to resolving these and other problems is realizing that you have rights. Here are some tips on how to take charge and get the health care you need:
* Understand your coverage. Familiarize yourself with your health plan’s benefits, policies and procedures. This information should be contained in the materials provided by your health plan and is usually called an “Evidence of Coverage,” or EOC, or “Summary Plan Description.” This is essentially your contract with the plan. So if there are parts you don’t understand, or if you can’t find your EOC, call your health plan’s customer service department, your employer, or your insurance agent or broker.
* Keep good records. Get in the practice of keeping a written record of your contacts with your doctor, your medical group and your health plan. Make a note of the date you called, whom you talked to and what you were told. If a problem arises, this information may be important to getting the help you need. Organize your medical records, health plan documents and billing records so that they are easy to find.
* Understand your medical condition. It is important to learn about your medical condition and to talk openly with your doctor about your concerns and treatment options. When you visit the doctor, you may want to take a list of questions and notes about your symptoms. Ask your doctor where you can get more information. You can also research your medical condition at public libraries, through support groups and on the Internet.
If you have a problem, there are a number of steps you can take. No matter what you do, be persistent and take notes. If you don’t get a timely response to your question or problem, call again. You may want to write to your medical group or health plan if you aren’t able to get an answer over the phone. Many problems can be resolved by a simple phone call, but in some cases you may need to write a letter or file a formal appeal or grievance.
* Talk to your doctor. Your most important health-care relationship is the one you have with your doctor, nurse or other health-care provider. Your doctor should be your partner in health care. Choose a doctor you feel comfortable with, who answers your questions and fully explains your treatment options. If you feel you can’t talk to your doctor, you have the right to change doctors.
* Contact your medical group. In many health plans, when you choose a primary-care doctor youare automatically assigned to his or her medical group. Most medical groups have patient assistance departments that can help you find a doctor, work out billing problems, or help you obtain necessary referrals and authorizations for services.
* Call your health plan. A customer service representative at your health plan should be able to explain the plan’s policies and procedures. Many problems can be resolved if you work with your health plan. Your plan can also tell you how to appeal a decision or file a grievance.
* Consider getting someone to help you. When you are sick, you may not be your own best advocate. Consider having a family member or friend make calls for you or go with you to appointments. You can also seek help from independent sources. Unfortunately, there is a patchwork of resources whose availability depends on how you get your care and the type of health plan you are in.
If you are eligible for Medicare and live in Los Angeles County, you can call the Center for Health Care Rights at (800) 824-0780; if you live in other counties, call (800) 434-0222. If you are low-income or receive health insurance through Medi-Cal, call the Health Consumer Center of Los Angeles at (800) 896-3203. And if you are in an HMO, call the California Department of Corporations’ HMO hotline at (800) 400-0815. (The Department of Corporations is the regulatory agency for HMOs in the state.)
Also if you are thinking of writing a letter to your health plan, the Center for Health Care Rights is launching a new Web site (https://www.healthcarerights.org), which will have sample letters you can use along with links to other consumer resources.
The main thing to remember is that it’s your health and you have the right to quality care. The best way to make sure that happens is to take charge.
Peter V. Lee is executive director of the Center for Health Care Rights, a Los Angeles-based consumer advocacy organization.
