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When You and Your HMO Don't See Eye to Eye

Sometimes even managed care members are unpleasantly hit with unexpected charges from their health care provider.

WebMD Feature

Members of managed care plans often say there'san advantage to paying a fixed monthly premium to cover most of their medicalcosts. They might shell out the occasional co-payment for a doctor's officevisit or prescription medicine, but they generally face no major healthcare bills beyond the monthly premium (or their share of that premium iftheir employer pays some of it).

That's the way it's supposed to be, anyway. But sometimes even managedcare members are unpleasantly hit with unexpected charges from their healthcare provider.

A Common Scenario?

You take a nasty turn on a ski slope while on vacation. On the advice ofthe ski patrol, you check in at the local emergency room to have your knee-- now the size of a small cantaloupe -- examined. You check into yourmanaged care plan's hospital, assuming they'll cover just about everythingbut the long-distance calls to friends and family. Yet a month later youget the bill, which claims you owe much more than just phone charges. Youget billed for services from the emergency room, the doctor and the radiologylab, plus in-hospital lab testing and X-rays that you thought would becovered.

Strategies for Success

What to do? Here's advice from consumer advocates:

Victoria Ross, a counselor at the Health Rights Hotline -- a pilot projectin Sacramento, California -- helps consumers navigate their health careplans. Her advice in our hypothetical situation? First, find out if it'sa paperwork mistake. If you've been billed for emergency room charges,call up the provider and be sure they have the correct information.

In many cases, she says, it's simply an error. Perhaps the emergencyroom clerk who checked you in was busy and marked you as uninsured, a mistakethat prompted the accounting office worker to send the bill to your homeaddress instead of your managed care plan's address.

So if you've received an unexpected hospital bill, call the managedcare plan's business office to see if it's a mistake. Sometimes the laboratoryor radiologist may be billing you, even though their services are covered,because your managed care plan has not yet paid them. Find out if thatis the case.

If the extra charges are not a mistake and you're still expected topay, review your plan's coverage information, Ross says. Determine if theservices you're being billed for are actually covered benefits. If theyare, bring it to the attention of your plan's member services department.

If the services you've been charged for are not covered -- but you thinkthey should be -- you can still appeal the decision. "Ask for a review,"says Mohit Ghose, a spokesman for the American Association of Health Plans,a Washington-based national trade organization. How to ask for one? Checkyour plan's coverage information or call the member services department.Every managed care plan has an internal appeals process.

As you work your way through the problem, you will no doubt make severaltelephone calls to your managed care plan's offices. On the first call,ask the representative you speak with for his or her name and telephoneextension, suggests Mary Jo Payne, a spokeswoman for California HealthDecisions, a nonprofit advocacy organization in Orange, California. Thenon future calls, ask to deal exclusively with that person. You'll avoidhaving to repeat your story a dozen times.

Ounce of Prevention

To help avoid future problems, consumer advocates suggest you develop afew common-sense habits. When you call your health plan to authorize servicessuch as out-of-area care, always get the name of the person you talkedto and the time and date. Jot down the gist of the conversation.

If you received medical care out of your plan's area and don't see anypaperwork after a month, don't assume no news is good news, Ross says."You want to be sure the bill was paid in full," she says. Call your healthplan's offices to see if it was paid. If your provider hasn't gotten abill, call to be sure the provider or the hospital and doctors aren't waitingon payment from you, possibly jeopardizing your credit.

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