Gaining Full Value Of Health Benefits
Michelle Andrews
Jan 14, 2001
When Bob Mendham ruptured a disk after hoisting a heavy toolbox into his car last winter, the pain in his back got so bad he could barely walk. The 44-year old state trooper from Dewitt, Mich., actually had to crawl to the bathroom.
But Mr. Mendham's back pain was nothing compared with the agony he went through trying to get his health plan to pay for the surgery he needed. His doctor had recommended a less-common procedure that was also less-invasive and a lot cheaper. But it wasn't on his plan's "approved" list, so his request for coverage was denied -- at first. After five months of appeals, his persistence finally paid off. "Until this happened, I'd always thought I had excellent insurance coverage," says Mr. Mendham, who's covered by a Blue Cross Blue Shield managed-care plan for state employees. "This was a real eye-opener."
Mr. Mendham's experience is hardly unique. Health-plan headaches are becoming commonplace: More than half of 2,500 people surveyed by the Kaiser Family Foundation had problems with their health plans, including denial of access to certain treatments, difficulty getting in to see a doctor and billing snafus.
Demand Your Rights
Moreover, 40% of people in the Kaiser survey didn't even know they had the right to appeal a health-plan decision to the state or an independent medical expert. A measly 6% of people with problems actually filed an appeal.
If you get turned down for care that you think is or should be covered under your plan, don't give up. You can fight back and win.
Your first step is to appeal the decision directly to your health plan. Health plans generally are required to have an internal review panel that re-evaluates all types of coverage decisions. If you lose that appeal, hit 'em again. Many health plans have a second level of internal appeals for people turned down once.
If you're still not satisfied, call the agency that regulates health plans in your state, usually the insurance department. They can help resolve some problems. And they can tell you how to appeal your decision to an outside, independent review panel in the 40 or so states that allow them. Appeals at this level succeed about half the time, says a report by the Institute for Health Care Research and Policy at Georgetown University. (Usually you must first exhaust the internal appeals process set up by your insurer.)
Other Resources
Need help filing an appeal? The Patient Advocate Foundation (800-532-5274) mediates disputes between consumers and insurers. Some states, like Vermont and Maryland, also have special health-care ombudsmen to help consumers.
Whether you're filing an internal or external appeal, you'll improve your chances by pulling together documents to support your case. These can include letters from doctors, medical records, even published articles from medical journals. Some states require health plans to give you access to the documents it used to deny your care. If your state does, get them. "The best way to fight health plans is with their own documents," says Sharon Ash, a health-care attorney with Landy & Seymour in New York.
In his battle with Blue Cross Blue Shied, Mr. Mendham appealed to the company twice, involved his union and called the Patient Advocate Foundation before the company relented. Says Mr. Mendham, "I guess they finally figured out I wasn't going to go away."
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