Believe it or not, health care companies are not invincible. It's possible to challenge an HMO's decision and win.
Unfortunately, most patients fail to take advantage of their appeal rights, and many still pay bills they don't have to. The biggest problem for consumers is the time and energy it takes to pursue complaints. But if you lose on your first appeal, you have a good chance of winning on a second appeal. Patients who lose on a second appeal can then contact independent state review boards or consult a lawyer.
Many insurers have found it simply isn't worth their time to fight in borderline cases. Although their rules may seem strict, insurers often find it’s more cost effective to grant a patient's request rather than to waste money fighting it. However, battling health-plan providers requires knowing how to successfully navigate the bureaucracy: Don't call, instead, write a letter acknowledging receipt of a denial. State the grounds as you understand them. Attach copies of medical records and don’t sound angry. Make a reasonable argument, backed up by evidence, showing why the procedure is "medically necessary."
If your appeal is rejected, appeal again. The first refusal may offer several reasons for rejection of coverage. The second letter will likely focus on the key reason for refusal. Get a letter from your doctor, and even a second opinion from another doctor, showing why the procedure was a medical necessity. Look for articles on the Internet or in professional medical journals that show the procedure is an accepted medical treatment.
Don't give up if you get a second refusal. Even though the letter states: "This is your final appeal," it's worth another step. Write one more letter asking if there's anyone else in the company you should talk to. Be sure to say that you've exhausted your internal options. This will pave the way for outside options such as a state review board or legal action.
State review boards, made up of medical specialists in the disputed area, review records from the case and medical literature. Forty-two states have set up independent review boards with the power to overrule insurers. You can expect a fairly quick decision, usually within 60 days or less of filing, and much faster if you can show your case is an emergency. The appeal is either free or costs a small filing fee. You needn't hire a lawyer, but many people find they need some expert help to navigate the system. And getting the necessary back-up material together may take you weeks or months. Most states give full information on what and how to appeal on their Web sites.
An important step: be sure to check whether Medicare covers the treatment you're appealing. Medicare hires private contractors to process claims. These contractors are often units of big, private insurers, so their rules influence how insurers act, even in non-Medicare cases.
Remember, too, that insurers often make simple bureaucratic mistakes. Read the fine print in your policy and don't be afraid to contact health plans, doctors and state regulators. Remember to keep detailed records so that you can refer back to them. Keep a log of all calls and save all correspondence. Keep a record of all authorizations and the names of people you've spoken to. Get a copy of your policy and the employee policy booklet. The health plan is usually accountable for whatever it promises in the booklet, even if the fine print of the policy says something else.
Professional Help: If you still need help, contact the Patient Advocate Foundation, a national non-profit organization. Call 1-800-532-5274 or visit them at www.patientadvocate.org.
Para solicitar información en español, llame al 1-800-ACS-2345. Un especialista en información sobre el cáncer le asistirá en español.
Spring/Summer 2003 Updated 9/1/'04
