Your Rights Under Your Health Care Plan

What's worse than being sick and needing health care? Being sick and not able to get the care you think you need, or being sick and finding out that you'll have to bear way more of the cost than you had planned. As a result of managed care, this happens much more frequently than it used to.

Thanks to the laws and regulations in many states, you now have the right to complain to your managed care provider and get a hearing. If all else fails, you may also have the right to file suit against the company.

Your lawyer can fill you in on your options in your particular case. Here is some general information that will illustrate the range of options you may have.

What Can Go Wrong
Imagine the kind of disputes that might arise. You might disagree with your plan about whether certain services are covered, what treatments should be followed, which providers should be used, or how much a service should cost. You might even have a dispute over billing and administrative mistakes.

If you have a dispute with your health care plan, you have a few options to assert your rights and seek redress.

Seeking Internal Review
Health plans are required to establish rules and procedures for handling complaints and grievances internally. Utilizing these procedures is an important first step in seeking resolution of a dispute. You can start an internal review with a phone call to a complaints hotline. You may need to follow it up with a complaints form or a written complaint. Some sample letters seeking review can be found at: http://www.healthcarerights.org/letters/lettersindex.html.

Check your plan to see how long a review is likely to take-it can be anything from one business day to thirty days. If your dispute concerns the medical necessity of services to be provided and your health would be seriously jeopardized by waiting for a standard review, you may be eligible for an expedited review and the plan will evaluate your dispute sooner.

Seeking External Review
External review allows your case to be reviewed by a third party independent of the health care plan. Most states have external review procedures, which can be pursued once internal review has been exhausted. Your health care plan may automatically refer your dispute to external review if your internal review is unsuccessful; or you may need to request external review in writing within a certain time period after internal review.

In most states, not every dispute can be reviewed, only those involving, "medical necessity." That means that there must be a dispute between you and your health plan over whether a particular procedure, treatment, or pharmaceutical is essential for your health and recovery.

The external review procedures are different in each state, but are usually free or available for a small fee. You can find a useful summary of the procedures involved in each state at: http://www.kff.org/consumerguide/states.html

Do You Have Access to External Review?

There are some plans that do not have access to external review. These plans are employer-aid "self-insured plans," and under the Employee Retirement Income Security Act of 1974 (ERISA), they are exempted from the state's external review procedures. Consult your employer's human resources department to determine if your plan is self-insured. If it is, then you probably cannot use your state's external review process.

Some Other Options
Complain to the accrediting organization. Most HMOs are accredited with non-government groups such as National Committee for Quality Assurance [www.ncqa.org], American Accreditation HealthCare Commission/URAC [www.urac.org] and the joint Commission on Accreditation of Health Care Organizations [www.jcaho.org]. HMOs rely on their accreditation by these organizations in their marketing to employers and unions. Making a well-documented complaint to the relevant organization and copying in your HMO might have results.

Make a complaint about your doctor-and seek a second opinion. If you think your doctor is withholding treatment, then talk to your doctor about it. You might want to seek a second opinion about whether treatment is necessary. And if you believe your doctor is withholding treatment for his or her own pecuniary gain, you can file a complaint with your state's medical board.

Prevention is Better Than Cure
Disputes with your health care plan are likely to come at the worst possible time-when you're seeking medical help. It's a good idea to minimize the chance of a dispute developing by becoming familiar with the details of your plan and understanding your coverage. It's also worth reading details of your plan's review procedure, so that if a dispute arises that needs urgent resolution you will know what your options are.