Endless POFibilities -- July 2001

Health Insurance, Managed Care, and Your Rights
by Jacqueline Fox

If you have a managed care plan (and most people do) you need to be very aware of your rights and your plan’s responsibilities. If you have an unusual medical condition that requires people to think outside the framework of basic preventive medicine, you need to do more. No matter what type of insurance you have, you need to get a copy of the contract that governs your insurance. The benefits handbook that you are often given is worthless, and usually says so on the inside of the front cover. It means nothing about the specific terms of your coverage and you need to know those specifics.

You can have health insurance from a number of different sources. Your employer might pay for the plan, you might have a policy you purchased yourself. The person who pays for your coverage determines the law that governs your rights. If you get health coverage from your employer, you
usually cannot sue for any damages the health plan causes you. If you buy an individual policy, you do have the right to sue, and that can give you more leverage when you negotiate with them.

Before it gets to suing anyone, however, there are things you can do to make sure you get the care you need.

In HMOs, if there is no doctor in the network who is qualified to handle your condition or the treatment that you require, you usually have a right to have a doctor outside the network provide that treatment and your HMO should pay for it at the regular cost of an in-network office visit. Ask your primary care doctor for a referral and be ready to appeal any denial that might stand in your way. Even if your doctor refuses to give you a referral, appeal that. Read through your contract and look for any language
that discusses qualified physicians or specialists or any other language that seems applicable and quote from it in your appeal.

If you have a PPO, the issue becomes getting your treatment paid for at an in-network rate if there is no in-network expert available and you have to go elsewhere. Again, read your contract and see if it promises to pay for this. Even if it doesn’t appear to, it is worth trying to appeal. For anyone, remember there is usually a cap on out-of-pocket expenses in any given year. The cap does not cover expenses that are in excess of the “usual and customary” costs, a figure the insurance companies announce is
the maximum they will pay for a certain type of treatment. While this amount is appealable, it is rarely overturned. The way to handle that is to talk to your caregivers in advance. Many hospitals and doctors will accept the usual and customary amount that your insurance company pays even if they aren’t part of the insurance company’s network. Ask the hospital separately from the doctor. My experience is that they are more likely to agree to this than a doctor is. This can really save you money.

If a treatment that you need for non-fertility reasons is denied as a fertility treatment, or if you run into any other denial that makes no sense, you have to appeal. Go to your contract and read it carefully with a highlighter and mark off any sentence that seems to apply. After you have figured out the definition of the reason for denial they gave you (for example, medical necessity means…) copy that exact language into a letter to your doctor and ask them to explain why the procedure does, or does not fall within the language form your contract. Then you need to do the same thing in a letter to your insurance company. Quote from the contract and explain why it supports you, not the insurance company. Whenever you quote, put the page number, title of the contract, section, paragraph and any other thing you find that identifies the exact place you got your language from.

This is not easy, and it is very wearing when you do not feel well. Consider appointing a loved one to be your advocate. Have them sign a release giving them access to your health insurance and medical records. If that doesn’t work, hire a lawyer who has experience in patient advocacy. You are dealing
with your health and you shouldn’t let the managed care industry ration the care you receive when you are entitled to more than that.

Jacqueline Fox is scheduled to speak at the 2001 IPOFA Conference! Don’t miss her session, “Maximizing Your Health Insurance.”

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