[MOL] Ins. Info. Series, Part 6... [00729] Medicine On Line

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[MOL] Ins. Info. Series, Part 6...

      To pay or not to pay? You make the call:
     A 13-year-old boy suffers a head injury in a motorcycle accident. After getting out of the hospital, he has trouble learning in school because his movements and perception have been affected by brain damage. The family seeks out a brain injury center for therapy, but the health insurance company refuses to pay, arguing that the policy’s language excludes therapy for “educational” problems.

      Typically, the family would be out of luck. Most health plans have the latitude to make decisions about whether a treatment is covered. Fortunately for this family, the insurance company gives its toughest cases to an independent, outside organization called the Center for Health Dispute Resolution. After examining the medical records and doing some research on treatment of brain injury patients, the center came up with a compromise: The health plan paid for some of the therapy, while the boy's school system paid for the rest.
      Why would an HMO allow an outsider to make a decision that could end up costing lots of money? For credibility. Increasingly, health plans are recognizing that the backlash against HMOs is being fueled by the perception that they have a conflict of interest: The less care they approve, the more money they make.
      So, to build trust with their members and the public, more HMOs are agreeing to set up external review processes that leave the final decision on tough calls to a third party. In fact, the California Association of Health Plans recently announced that most of its members would establish such reviews by the end of 1999.
      This is good news for consumers, but it's qualified good news. Not every external review is created equal.
      For example, a plan could send its unresolved disputes to a single, outside physician beholden to the insurer. Or a plan could restrict the types of disputes that make it to third-party review — allowing an outside opinion on whether a patient should be referred to a specialist, but not on whether that specialist's bill would be covered. Another way to cheap out is to leave out any time limit and allow the review process to go on forever.
       External review is a big political issue nationally. It’s likely to come up in the next Congress, when legislators again consider patients’ rights bills that offer various requirements for outside review.
      But until then, the likelihood that you'll have access to this kind of independent dispute resolution is a shot in the dark. If you fall into one of the following categories, your health plan should offer third-party review:       

      If you're unsure whether you fall into one of those categories, call your health plan's customer service people or contact your company's employee benefits department. To check on your state's rules on external review, contact the state agency that regulates HMOs. It should be an insurance or health department; some states, like California, make that agency even tougher to find by putting HMO regulation under the Department of Corporations. Here's a state-by-state list.
      The best way to arm yourself in these HMO wars is to know your rights. Find out what the appeals process is for your insurer, and know what your state requires the health plan to do. Also, your state may have a separate process of its own that you can use to appeal a health plan decision.
      If you disagree with a decision your doctor or medical group has made, complain to the medical group before you go to the health plan, because the doctors may have actually taken on much of the responsibility for these decisions. And be sure to file an appeal quickly after the dispute occurs, so you don't miss any legal windows of opportunity. For more step-by-step advice on complaints, check the Web site for Citizens for the Right to Know.
      Of course, all this dispute resolution is necessary only if you get into an intractable disagreement with your insurer. Hopefully it won't come to that, but it's likely that patients and health plans will be doing battle with one another more often. Consumers are becoming more aware of their rights and are more likely to fight for coverage they think they deserve. And people are finding that they disagree with their plans more often. A recent survey by the Kaiser Family Foundation found that 57 percent of Americans polled said either they or someone they knew had had a problem with a health plan in the past few years, compared with 48 percent who reported a problem in a survey nine months earlier. Also, consider the fact that health plans are losing money almost as fast as they were making it just a few years ago, and they'll be looking for ways to tighten the reins on your use of their services.

Warmly, lillian

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