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Making Them Pay: How to Get the Most from Health Insurance and Managed Care
     

Making Them Pay: How to Get the Most from Health Insurance and Managed Care

by Rhonda Orin
 

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Most people don't understand health insurance, and insurance companies know it. Unfair denials, late payments, and hopeless confusion are the norm. At last there is a solution. In eight easy steps, Making Them Pay gives practical advice about the things that drive people crazy. Like:

-Figuring out what health plans really say
-Understanding what

Overview

Most people don't understand health insurance, and insurance companies know it. Unfair denials, late payments, and hopeless confusion are the norm. At last there is a solution. In eight easy steps, Making Them Pay gives practical advice about the things that drive people crazy. Like:

-Figuring out what health plans really say
-Understanding what benefits they provide
-Finding, and understanding, the exclusions
-Determining what health plans really cost
-How to talk to customer service, and other painful details
-Easy ways to keep good records
-Laws that can change your life-like the mandatory benefits laws in all fifty states
-How to prepare successful appeals

Along with this useful advice, Making Them Pay offers a much-needed sense of humor. It's filled with cartoons, sidebars, and vignettes that will make you laugh as you learn. Based on Rhonda D. Orin's extensive experience as a litigator, a journalist, and a mother fighting her own family's insurance battles, Making Them Pay is the book your health insurer doesn't want you to read.

Editorial Reviews

Mike Maza
Ms. Orin is an expert.... [In Making Them Pay, she explains] how to compare health insurance plans beyond the vague booklets.... Also: How to decipher your policy's benefits, and tips for getting the company to actually pay off. —The Dallas Morning News
Library Journal
In this consumer guide to health insurance and managed care programs, lawyer Orin has assembled a compact reference that explains how to read and understand a health plan and how to go toe to toe with insurance companies to get the benefits to which we are entitled. The author outlines the components of typical plans the services covered and the limits and exclusions insurance companies and managed care systems may apply to deny coverage. The chapter on challenging insurance companies over the denial of coverage or other problems is detailed and insightful. Orin emphasizes record keeping and shows readers how to deal with customer service representatives to make sure the problem or complaint is documented. She includes a survey of statutorily required coverage for each state, complete with citations to state laws and lists of state insurance commissioners, attorney generals, and other advocacy groups. This book simplifies a convoluted subject and is recommended for most public libraries. Joan Pedzich, Harris, Beach, & Wilcox, Rochester, NY Copyright 2001 Cahners Business Information.

Product Details

ISBN-13:
9781429979108
Publisher:
St. Martin's Press
Publication date:
04/01/2011
Sold by:
Macmillan
Format:
NOOK Book
Pages:
256
Sales rank:
1,034,389
File size:
1 MB

Read an Excerpt

Making Them Pay

How to Get the Most from Health Insurance and Managed Care


By Rhonda D. Orin

St. Martin's Press

Copyright © 2001 Rhonda D. Orin
All rights reserved.
ISBN: 978-1-4299-7910-8



CHAPTER 1

THE NUTS AND BOLTS

STEP ONE

LOOK OVER YOUR HEALTH PLAN AND FIND THE KEY PIECES


It's time to get down to business — and that means learning the nuts and bolts of health plans. I hate to say it, but you just can't avoid this part. Whether you are trying to pick a health plan or to figure out if something is covered under the one you've got, you need to know how to read a plan.

This chapter is about learning an approach — nothing more than that. The approach is one you should follow with any health plan (and, to a certain extent, with any contract at all). You should follow this approach to figure out if you're covered for anything — from open heart surgery to childhood immunizations. This is basically the same approach that a Supreme Court justice would follow, or a claims examiner at your insurance company for that matter. As far as I can tell, it's the only way to do it.

The first step is simply to find all of the important sections. Don't try to study them in any detail, or spend any time figuring out what they mean. At this point, just finding them is enough; you'll do the rest in Steps Two and Three.

Believe me, finding the key sections is not as easy as it seems. While all health plans contain the same basic sections — like benefits, exclusions, definitions, and so on — each plan seems to put these sections in a slightly different order and to use different titles and terms. Learning how to find them all is more than enough for Step One.

To figure out the structure of your plan, it's best to work with an example. Let's say you have allergies, and you want to know if they're covered under your health plan. Let's say that your health plan is the composite one that's set forth in Appendix A.

By the way, I created this composite, rather than using an actual plan as an example, because I wanted to show that this approach works for all plans, not just for a particular one. This composite is an HMO plan with a Point-of-Service option, meaning the right to see doctors outside the plan, and to submit the bills for reimbursement the old-fashioned way. Its text, and its basic format, is drawn from a number of actual plans.

This composite may seem much more detailed than the materials you've been given about your own plan. Sometimes people have nothing more in their files than one- or two-page summaries of their benefits, usually in a column format. If that's all you have, you're entitled to much more information — and you definitely will need it in order to understand your coverage. Accordingly, it would be a good idea for you to contact your employer or your insurance company and ask for a copy of the entire contract and/or a short version known as the Summary Plan Description or SPD.

By now you know that your first step is just to locate all the important sections, starting with the Benefits. You also know that you're learning an approach — you're certainly not learning whether or not a particular condition actually is covered under a particular health plan.

In fact, if you want to do a quick test of your insurance knowledge, turn to the composite plan in Appendix A right now and see if you can identify all of the sections that relate to allergies. Then, return to this chapter and see if there were any that you missed.

For everyone else, let's get started.


1. THE BENEFITS

It's pretty easy to find the Benefits section in your health plan. It starts at the end of the plan's seventh page. (Remember what I said in the Introduction about not starting on page I?) In fact, you'll find five entirely different Benefits sections. They are labeled as (1) Medical and Surgical Benefits; (2) Hospital/Extended Care Benefits; (3) Emergency Benefits; (4) Mental Conditions/Substance Abuse Benefits; and (5) Prescription Drug Benefits.

Before we're done, I'll end up suggesting that you skim through all five of these sections. For starters, though, you should focus on the Medical and Surgical Benefits subsection. When you turn to it, you'll find a page that looks like this:


1. MEDICAL AND SURGICAL BENEFITS

A. What Is Covered


A comprehensive range of preventive, diagnostic, and treatment services is provided by Plan doctors and other Plan providers. This includes all necessary office visits; you pay a $5 office visit co-pay, but no additional co-pay for laboratory tests, X rays, and prenatal office visits. You pay nothing for well-child care for children under five years of age. Within the service area, house calls will be provided if in the judgment of the Plan doctor such care is necessary and appropriate; you pay nothing for a doctor's house call, or home visits by nurses and health aides.


The following services are included and are subject to the office visit co-pay unless stated otherwise.

• Preventive care, including well-baby care and periodic check-ups (co-pay waived for well-child care for children under age five)

• Voluntary sterilization and family planning services

• Diagnosis and treatment of diseases of the eye

Allergy testing and treatment, including testing and treatment materials (such as allergy serum). You pay nothing. Emphasis added.

• The insertion of internal prosthetic devices, such as pacemakers and artificial joints

• Cornea, heart, heart-lung, kidney, liver, lung (single and double), pancreas and pancreas-kidney transplants; allogeneic (donor) bone marrow transplants; autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute lymphocytic or nonlymphocytic leukemia, advanced Hodgkin's lymphoma, advanced non-Hodgkin's lymphoma, advanced neuroblastoma, breast cancer, multiple myeloma, epithelial ovarian cancer, and testicular, mediastinal, retroperitoneal, and ovarian germ cell tumors. Transplants are covered when approved by the Plan Medical Director. Related medical and hospital expenses of the donor are covered when the recipient is covered by this Plan.

• Women who undergo mastectomies may, at their option, have this procedure performed on an inpatient basis and remain in the hospital up to forty-eight hours after the procedure.

• Dialysis; you pay nothing

• Chemotherapy and radiation therapy; you pay nothing

• Inhalation therapy

• Surgical treatment of morbid obesity

• Orthopedic devices, such as braces; foot orthotics, including replacement or adjustment limited to that necessitated by the member's physical changes or growth


The section continues, and you should skim the whole thing, but you've already found what you were looking for in the highlighted section: "Allergy testing and treatment, including testing and treatment materials (such as allergy serum). You pay nothing."

In isolation, it sounds great, but nothing in an insurance policy is in isolation. So turn back to the introduction to this list of benefits and read it again — very slowly and very carefully.

Sure enough, you bump right into a hidden qualification. Before you continue reading, see if you can find it for yourself. Here are the key sentences:


A. What Is Covered

A comprehensive range of preventive, diagnostic, and treatment services is provided by Plan doctors and other Plan providers. This includes all necessary office visits; you pay a $5 office visit co-pay, but no additional co-pay, for laboratory tests, X rays and prenatal office visits. You pay nothing for well-child care for children under five years of age. Within the service area, house calls will be provided if in the judgment of the Plan doctor such care is necessary and appropriate; you pay nothing for a doctor's house call, or home visits by nurses and health aides.

If you pointed to "all necessary office visits," you win the prize. This is a major hole. It basically means that someone has to decide your office visits were "necessary" for there to be coverage. And that person — whoever it is — might not see eye to eye with you (or even with your doctor) about what exactly is "necessary."

But for now, let's say you hit the jackpot. Your primary care doctor decides you have allergies that require treatment. So he or she refers you to an allergist and you start treatment, right?

Not so fast. All you get, at this point, is one or two visits with an allergist. If you want to stay within the HMO and avoid paying for a percentage of the visits yourself, the basic plan is for your primary care physician to stay in charge of your care. And — this is the deal whether or not your primary care physician knows boo about allergies.

The words that set this limitation are hidden away in my favorite section, the innocent-sounding one called Facts About This Plan:


3. Referrals for Specialty Care

Except in a medical emergency, or when a primary care doctor has designated another doctor to see patients or when you choose to use the POS benefits, to receive standard HMO benefits you must contact your primary care doctor for a referral before seeing any other doctor or obtaining special services. Referral to a participating specialist is given at the primary care doctor's discretion; if specialists or consultants are required beyond those participating in the Plan, the primary care doctor will make arrangements for appropriate referrals.

When you receive a referral from your primary care doctor, you must return to the primary care doctor after the consultation unless your doctor authorizes additional visits. For standard HMO referrals, all follow-up care must be provided or arranged by the primary care doctor. On referrals, the primary care doctor will give specific instructions to the consultant as to when services are authorized. If additional services or visits are suggested by the consultant, you must first check with your primary care doctor. Do not go to the specialist unless your primary care doctor has arranged for and the Plan has issued an authorization for the referral in advance.

If you are "lucky" enough to be really sick, though, your primary care physician has the power to turn over your care entirely to the allergist. The words that give him or her this power appear at the end of this section:

If you have a chronic, or serious medical condition that causes you to see a Plan specialist frequently, your primary care doctor will develop a treatment plan with you and your health plan that allows an adequate number of direct access visits with that specialist. The treatment plan will permit you to visit your specialist without the need to obtain further referrals.

This sounds good, but you should appreciate that behind the scenes at HMOs, various incentive structures — or penalty provisions — may keep your doctor from acting on this provision. HMOs keep records of everything done by their primary care doctors, and many of them assert liberal rights to remove doctors from their plans. So no matter how sick you are — and certainly if you're a borderline case — there are a lot of reasons why you may not be given the right to unlimited visits. (Some insight into your doctor's perspective is set forth in Step Two.)

Before moving past the Benefits section, take a minute to skim each of the other subsections. You'll need to see if there is anything specific to allergy coverage there, since there may well be. Prescription coverage, for example, can be valuable for someone with allergies, and some plans specifically refer to allergy medications in these sections. Similarly, emergency care and hospitalization can be important issues, especially for someone with a potentially acute allergic condition like severe asthma.

Your quick check should show that there are no specific provisions about allergies in these other subsections. You'll still need to look them over, as discussed in Step Two. But for now, it's time to move on to the Exclusions.


2. THE EXCLUSIONS

Exclusions are found all over health plans. Usually, they appear in the Table of Contents, under a heading called Exclusions. But they are also found in many other locations, and under many other headings. Watch out — especially when you're deciding which health plan to buy.

This particular health plan lists General Exclusions on the seventeenth page. This section is all of three inches long. If you didn't know better, you might think that this health plan doesn't have many exclusions. Boy, would you be wrong.

This is the entire General Exclusions section:


SECTION VI: GENERAL EXCLUSIONS

The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness or condition as discussed under Authorizations. We do not cover the following:

• Care by non-Plan doctors or hospitals except for authorized referrals or emergencies (see Emergency Benefits) or eligible self-referral services obtained under Point-of-Service Benefits;

• Expenses incurred while not covered by this Plan;

• Services that are not required according to accepted standards of medical, dental, or psychiatric practice;

• Procedures, treatments, drugs, or devices that are experimental or investigational;

• Procedures, services, drugs, and supplies related to sex transformations; and

• Procedures, services, drugs, and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest.


You won't need to pay attention to the last three exclusions. The allergy coverage that you are looking for is not experimental, and definitely does not require a sex transformation or an abortion. But the first four exclusions — which are much more general — are a different story.

These exclusions make clear (sort of) that you're going to have trouble getting coverage if you see an allergist who is not on the plan. They also repeat — twice — the same "necessary" limitation that was hidden in the Medical and Surgical Benefits introduction. This limitation appears in the introduction to this section: i.e., a service that is listed as a benefit "will not be covered for you unless your Plan doctor determines it is medically necessary ...." It reappears in the exclusion for "Services not required according to accepted standards of medical, dental, or psychiatric practice."

Guess what? Because of this limitation, you can't be sure that the allergy coverage you're looking for is covered under this plan. There's a fatal trap in the words "according to accepted standards of medical, dental, or psychiatric practice." Words like these usually mean "according to the symptom lists that this insurance company hands out to its employees, for use in evaluating claims." Since you don't get to see these lists, you don't know what they say — and you certainly don't know whether your symptoms are enough to get you the coverage that you want.

Just for the heck of it, it would be a good idea to call up your health plan and ask for its symptom list — or whatever they call it — for allergies. Most insurance companies don't release this kind of information readily, but maybe you'll get lucky.

Having exhausted the General Exclusions section, it's time to hunt around for other exclusionary language. You won't have to look far. Each of the five Benefits subsections has a section called What Is Not Covered. You won't find these sections in the Table of Contents, and they're not called Exclusions, but they nevertheless have the power to defeat your claim for health coverage. So you better find them all.

The What Is Not Covered part of the Medical and Surgical Benefits section looks like this:


C. What Is Not Covered

Physical examinations that are not necessary for medical reasons, such as those required for obtaining or continuing employment or insurance, attending school or camp, or travel

• Dental implants

• Reversal of voluntary, surgically induced sterility

• Surgery primarily for cosmetic purposes

• Homemaker services

• Hearing aids

• Transplants not listed as covered

• Long-term rehabilitative therapy

• Cardiac rehabilitation

• Chiropractic services

• Organ-donor-related transportation expenses

• Acupuncture services

• Blood and blood products


(Continues...)

Excerpted from Making Them Pay by Rhonda D. Orin. Copyright © 2001 Rhonda D. Orin. Excerpted by permission of St. Martin's Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

Meet the Author

Rhonda D. Orin is a lawyer with more than a decade of experience suing insurance companies on behalf of policyholders. She has presented cases in courts around the country, and two of her cases have been decided by the U.S. Supreme Court. She works in Washington, D.C.

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