Top Ten
Tips
On Consumer Advocacy
Effectively
Dealing with your HMO
Or, How to get your HMO to change a
"no" to your request for coverage to a "yes"
1. Persistently Insist; if what you need is more than just a want,
don’t take no for an answer.
2. Even if you are a doctor or health care
professional, you think and feel anxious like any lay-person. If your need
seems urgent or emergent to you, that’s good enough under the “Prudent Lay-person
Standard.” And, do not understate the
extent of your illness and injury.
3. Access people who know how work the system and who
are on your side. These include employee benefits administrators, your doctor's
office, or on the hospital's staff.
4. Be formal and ‘get it in writing.’ Contact the HMO by
return receipt requested letter and ask for a letter from them stating (a) the
medical reasons your claim was denied, (b) who was involved in the decision to
deny the claim, and (c) their particular clinical specialty or expertise to
make that determination. For instance,
if you are diabetic and need a test or procedure related in any way or possibly
affected in any way by your diabetes, ask if an endocrinologist was involved in
the decision to deny you your need.
5. Follow, to the letter, the appeals process, but
read the HMO contract, first because what you need may be a benefit
exclusion, otherwise known as gotcha.
6. If necessary, demand reconsideration from a
different medical director than the one whose name was on the first decision to
deny you your need, or by the HMO's administrative review board. Follow the appeals procedures exactly. If
you decide to pursue your claim to its final point—arbitration or litigation—you'll
have to be able to show that you've exhausted all possible appeals channels,
first.
7. Most policies have a 30 or 60 day grievance review
procedure. Also, an expedited review should be provided, if that is necessary. Seriously
ill Medicare HMO patients are entitled to a response within 72 hours under Expedited
Appeal rules.
8. Find a physician advocate, someone who cannot stand
the hoops they must jump through and who is willing to write to the HMO
explaining the reasons your claim should be allowed and CC The Department of Insurance,
your State and the other doctors recommending the kind of treatment you need.
Also, contact public advocacy groups such as the American Cancer Society.
9. Document well and be prepared for red tape--your
HMO has their version well-documented under what they call their “Auth”
screen and will remember only what they want to of the information sent them by
your doctor. This is the rub—your
doctor can easily state in a sentence or two at the outset what you need and
why, but they often don’t—unfortunately it’s their nature; it’s called
hyper-individualism. Anyway, keep all
medical bills and correspondences with the HMO. Take notes of all phone calls
with the HMO—the date of the call, the amount of time you spent on hold,
the name of the person to whom you spoke, what you said, and what was said to
you. If you have time, write a letter to the HMO summarizing the call. HMO's
are experts at red tape—beat them at their own game.
10.
Go Upstairs and ‘get
political.’ Let the regulators like the Department of Insurance, Health, your
Congressperson/Senator, even The National Commission on Quality Assurance
(NCQA) hear your gripe. Let the HMO
know you're doing all this because they frequently behave better when they know
state regulators are looking over their shoulders, particularly since many
state regulatory bodies keep a record of every consumer complaint they
receive. But, think twice before hiring
a lawyer, and if you do hire one, it's usually better for them to stay in the
background. Note: few claims involve
enough money to be financially attractive to lawyers, and when they become involved,
the HMO communicates only with them. If
you cannot afford a lawyer and need one, contact advocacy groups for your
particular illness or injury and also the local bar association. Alternatively, consider filing a claim by
yourself in a small claims court; you won't need a lawyer, and the court will
provide assistance in preparing the paperwork.
Anatomy of
a Denial
Good Bad
Demographics For
faster service,
Issues at Hand call
1-800-NUTS-TO-U
Contract
Language
Clinical Criteria
Why “No” is the Case
Appeal Rights