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Consumer Help Web Sites And Information

Below are tips for getting your HMO to change a "No" to your request for coverage to a "Yes".
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Be insistent; be persistent.
Insistence and persistence are the key. Patients should not take "no" for an answer.

Treat an emergency like an emergency.
If it's urgent, insist on immediate attention. Don't be afraid to demand the care you deserve. Strange as it may seem, many people understate the extent of their illnesses and injuries.

Get help.
Get help from the people who know how to make HMO claims and who are on your side. These include your employee benefits administrator, the people in your doctor's office or on the hospital's staff who usually know about making claims. They will frequently help patients with getting treatments and getting claims paid.

Get it in writing.
Contact the HMO, by letter if possible, and ask for a letter stating (a) the medical reasons your claim was denied, (b) the names of those involved in the decision to deny the claim, and (c) whether those individuals have clinical expertise in the area of medicine relevant to your problem. For example, if you are diabetic, ask if an endocrinologist was involved in the decision to deny your claim. Often, claims decisions are made by physicians without experience in the field relevant to patients' illness/injuries.

Follow the appeals process.
Find out how your plan's appeals process works: Contact your employer's benefits administrator or the HMO itself. Read the HMO contract.

If your case is not an emergency, demand reevaluation by the HMO's administrative review board. Follow the appeals procedures exactly. If you decide to pursue your claim to its final end -- arbitration or litigation -- you'll have to be able to show that you've exhausted all possible appeals channels.

Most policies have a 30 or 60 day grievance review procedure. An expedited review should be provided if necessary. For example, seriously ill Medicare HMO patients are entitled to a response within 72 hours.

Get doctors on your side.
Have your doctor write to the HMO explaining the reasons your claim should be allowed. Get a second opinion or obtain the names of other doctors recommending the kind of treatment you need. Ask these physicians to write to your HMO on your behalf. Contact public advocacy groups such as the American Cancer Society.

Be prepared for red tape.
Your HMO will probably have created its own version of the "facts" relating to the denial of your claim. Make sure that you have something other than just your recollection to back up your version of events. Write letters whenever possible. Keep all medical bills and correspondence 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.

Get political.
Call and write your state insurance department and department of health -- and let the HMO know you're doing it. HMO's 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.

If you're really annoyed, or it's really serious, write to your legislative representatives -- your state representative or senator, for example. They know that effective constituent service means votes. Again, send the HMO a copy of the letter.

Use lawyers with caution.
Think twice before hiring a lawyer. First, few claims involve enough money to be financially attractive to lawyers. Second, when a patient's lawyer gets involved, the HMO stops dealing with the patient and communicates only with the lawyer. As a result, if you do hire a lawyer it's usually better for the lawyer to stay in the background.

No-fee legal services are often available for those who cannot afford a lawyer. To find such a lawyer, contact advocacy groups for your particular illness or injury (such as the American Cancer Society) and the local bar association. Alternatively, consider filing a claim by yourself in small claims court. You won't need a lawyer, and the court will provide assistance in preparing paperwork.

Be insistent; be persistent.
For further information, contact Lia Royle, a partner in the firm's Washington, D.C. office, phone (202)728-3102


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