The High Price of Health
HOW TO CHALLENGE YOUR PLAN'S DECISION

Excerpt from Managed Care Made Easy:  Survival In The HMO Era by Vikram Khanna, M.H.S. The People's Medical Society, 1997 [Reprinted with permission of the Publisher]

USING THE PLAN'S CUSTOMER SERVICE DEPARTMENT

The plan's customer service department is the place to start. All managed care plans have customer service departments to answer questions and resolve minor complaints or misunderstandings with the plans. Here are some general guidelines when contacting the customer service department.

* Organize your thoughts. Make notes outlining your complaint, including the dates of important events and the names of people involved in the problem, such as your physician, plan employees or a hospital, if one was involved.

* Call the plan's customer service number (it should be listed in your plan's enrollment materials or on the back of your membership card) and explain your concern. You can also let your employer know about your problem by speaking with the person in your workplace who handles your company's health benefits.

* Describe your problem or concern in as much detail as you can. The plan's customer service representative will ask you for a history of the problem, and the better you can document your complaint, the more likely you are to have it addressed quickly and appropriately.

* Ask the representative to tell what specific additional steps you need to take, if any. For many complaints, the customer service representative may be able to help you resolve the question or problem over the phone.

* Ask the plan representative to tell you what steps he will take to address your question and when you can expect to hear from someone in the plan. Make a note of the representative's name, as well as the date and time that you called. Customer service representatives often need to go to other officials in the plan, such as the plan's medical director, to get information or have a decision made on your complaint or question.

* The customer service representative should get back to you within the time period you were told with an answer to your query. If he does not, follow up with the plan and ask to speak with a customer service department supervisor if the delay persists.

* If you are not satisfied with the representative's response to your concerns, ask to speak with a supervisor immediately.

Some complaints and questions cannot be addressed fully over the telephone. In these cases, which usually involve more serious problems such as denial of major surgery or denial of coverage for a new drug, you will need to file a written complaint with the plan. Also, you may wish to file a written complaint if your initial phone inquiry to the plan is unsatisfactory.

WHEN AND HOW TO FILE A WRITTEN COMPLAINT WITH YOUR MANAGED CARE PLAN

When you file your written complaint, depending on its specific nature, a number of different plan officials could review and act on your complaint. If the complaint is not related to quality-of-care concerns but instead deals more with a financial issue such as the plan's nonpayment of a bill, your complaint will most likely be reviewed by the customer service department or by plan officials who oversee the financial and administrative operations.

If your complaint involves a quality-of-care issue such as the plan's denial of medically necessary care, it will move from the customer service department to the plan's medical director. The medical director is a physician who oversees all medical aspects of the plan's operations. The medical director and his staff are responsible for all new policies related to the medical care you receive. The medical director often works in conjunction with committees made up of other plan physicians to review consumers' complaints and to make coverage decisions on specific issues.

The medical director and/or the designated committee reviews your complaint as part of the plan's grievance and appeals procedure--a process that should be outlined in your enrollment materials. (If you cannot locate this information, call the customer service office to get details, including specific directions for how to file a complaint, if you do not already have them.)

An important situation to watch for during an appeal or grievance is whether any of the personnel reviewing your complaint has a conflict of interest. For example, if you are appealing an earlier decision by the medical director over denial of surgery, the medical director should not be part of the appeals process. If anyone does have a conflict, that person's objectivity could be compromised. Ask who is reviewing your complaint. If anyone in that list of people may have previously made an adverse decision that is the basis for your complaint, request that he be excused from the latest review.

PREPARING YOUR GRIEVANCE OR APPEAL

In order to be effective in your grievance or appeal, you must be well prepared. Here are some tips and steps that will help you win your point.

* At the first sign of a problem--for example, your primary care doctor or plan refuses to refer you to a specialist when you believe you need one--start keeping notes. Carefully document each interaction with your physician or other administrators, noting the date of your conversations, what was said and by whom.

* If you disagree with your doctor about a clinical issue, ask him to clearly document in your medical record that you and he disagree. This is critical because your medical record is the official record of what transpires between you and your doctor. While it is his responsibility to maintain the record, it is your right to have your disagreement with him properly documented and also to see what he has written. If he refuses to enter your side of the story into the record, write him a letter documenting your side of the issue and deliver it to his office for placement in your file.

The Role of Second Opinion In A Grievance or Appeal

If your grievance or appeal is over a clinical judgment made by a primary care physician or specialist, ask the plan to pay for a second opinion from another similarly qualified physician. Getting a second opinion from another primary care physician or specialist may help you resolve your problem without the need to proceed with a grievance or appeal to the plan. Make sure you get authorization for the second opinion in writing from the plan to guard against any later disputes over who should pay for the second opinion.

* Ask your physician for a copy of your medical records, which should include lab results, reports from specialists and other information that may help you document the validity of your complaint. Be aware that not every state has a law guaranteeing consumers access to physician and/or hospital records. You should call your state health department to find out where your state stands on this.

If your state has no legislation or other ruling and--for the sake of this example--the provider denies you access to your own record, you may need to consult a lawyer.

* Once you assemble your documentation and your notes, you are ready to write your complaint letter. Attach copies of pertinent sections or your medical record to your letter, along with any correspondence you may have received from your physician or the plan relating to the matter at hand.

* Mail your letter to the plan official identified in your enrolling materials as the person who handles consumer complaints. Send the letter by certified or registered mail.

* Within seven to 10 days, contact the plan to find out who is handling your complaint and ask how quickly you can expect the plan to act. Because consumers in managed care plans have often complained about how long it takes to get complaints resolved, many plans prioritize complaints. If your complaint involves a quality-of-care issue, ask that the process be speeded up so that there can be a quick resolution. In point of fact, some states require plans to meet specific deadlines when acting on consumer complaints that involve any immediate threat to the life or welfare of an enrollee in the plan. Check with your state insurance or health department for its requirements in this regard.

* Follow up with plan officials frequently to assess the status of your complaint.

* If appropriate to your complaint, ask your primary care physician or specialist to help. Situations in which either or both can help include ones in which the plan refuses to approve a particular test or treatment ordered by the doctor. When this happens, your physician should write his own letter and submit it to plan officials. Make sure you get a copy.

* When your physician submits a letter supporting your grievance or appeal, make sure it is accompanied by copies of any medical studies or other expert opinions (such as letters from specialists) that help document why a disputed test or treatment is appropriate in your case.

* When your plan completes its review, insist that it provide you with a written decision.

Do not accept a verbal decision from the plan as resolution of your complaint. If the plan's customer service department or medical director's office calls with a decision, make note of the decision and the caller's name and title and then request a written statement so that there is a permanent record of the plan's action. You should provide a copy of your plan's decision to your physician for placement in your record. This is important if there is confusion later about what the plan told you , if the plan reneges on its decision or if you later pursue legal action against the plan.

*If you are not satisfied with your plan's decision, discuss the matter with your physician and consider pursuing the complaint with the state government agency that oversees complaints against managed care plans. If your are in a Medicare or Medicaid health maintenance organization (HMO), you may have special appeal rights available to you.

 

 
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