June 5, 2000 -- Nothing can be more frustrating or confusing than to show up at your doctor's office with symptoms of a health problem, only to be told you can't get the diagnostic test you want, a referral to a specialist, or a specific medical treatment.
Administrative appeals and legal recourse are possible long-term remedies, but in the meantime your health or life may be at risk. Although it's possible to beat your doctor or even your health plan in court, experts say patients are better off if they can settle such disputes without involving the legal system.
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"Consumers who have health or medical problems often feel overwhelmed or powerless, and it can be intimidating to confront your doctor or health plan," says Bridget Sheehan-Watanabe, health policy analyst and staff attorney for the Center for Health Care Rights in Los Angeles. "But once a consumer has an understanding of how to resolve the issues and knows where the problem lies, she can often be successful in getting the care she needs."
Before requesting an appeal ?- which can take several months to resolve ?- experts suggest a number of initial steps to expedite the process. Contacting an attorney can also help. The presence of an attorney and the threat of a lawsuit may make the doctor, hospital, or health plan take notice, experts say. Moreover, "Everything is negotiable," writes consumer advocate Jamie Court in his book Making a Killing: HMOs and the Threat to Your Health. Here are some tips:
Try to establish open communication with your doctor. Remain calm and reasonable. Find out why you were denied care and who denied it -- the doctor, the medical group, or your health plan. Did the doctor put in an authorization request and receive a denial? If so, make sure he or she gets involved in trying to get your benefits. If you feel intimidated or uncomfortable questioning your doctor, bring someone else with you. Put your questions in writing before going in, and take notes.
Ask your doctor how she is paid, and about any financial arrangements she may have with the medical group or health plan. If your doctor has a financial incentive to deny tests or referrals under "capitation," (where your doctor or a medical group is paid a set monthly fee per patient), you may be able to enlist the help of your HMO, which would face no added expenses, having already paid for the care you should receive.
Immediately ask for a second opinion from your physician's supervisor. Then get another opinion from a qualified professional outside the HMO network, if possible. "Find allies in the medical profession," says Jamie Court. "When medical experts advocate care, HMOs find it harder to deny treatment."
Go to the administrator in charge of your doctor's medical practice and explain the need for the test or treatment.
Request a written denial.
Document everything. Make sure your doctor documents your treatment and its necessity. Get a copy of your medical records.
Find out the timelines within which your treatment or coverage decision must be made -- taking into account the deadline when failure to get the test or treatment may result in harm to you. Most states have regulations establishing such time frames. Make sure you communicate clearly that you know the timeline and that it must be met.
Get a patient advocate. "This is important because you need someone to advocate for you who's not afraid to challenge anybody, because if you're sick, you're not going to do it," says Wanda J. Jones, president of New Century HealthCare Institute in San Francisco. Find out who can assist you; contact your state HMO regulatory agency or consumer advocacy groups.
When your health is at stake, you may have to resort to going outside the plan and paying for care directly. If the treatment is expensive and you're unable to pay for it, this may mean taking more drastic steps such as taking out a loan, getting a second mortgage, or asking for financial help from friends or relatives.