If you have been frustrated by the managed care industry, denied claims that should have been paid, refused a referral to a specialist and wondered what you could do to advocate for yourself:
1.Keep good records. Follow up all phone conversations related to billing/reviews/referrals with a letter- preferably certified. Keep your own copies of all lab work, specialists reports and diagnostic testing. Insurance companies who know you keep a paper trail will treat you fairly, and doctors who know you keep a record of their notes will document accurately. It also gives you a chance to correct any errors. Also, if you have any medical problems, you will have your records if a medical crisis occurs.
2. Keep a copy of your insurance policy- often available online. A copy is also available through your employer if that is who you are insured through. This will have the process by which disputes are handled and referrals are made.
3. Always keep track of who you talk to, talk to the supervisor when you can, and get their direct line. Be firm but polite.
4. Be honest about what it is you need, and why it is you need it. While you may be very frustrated by explaining your situation a million times, each person hearing it is hearing it for the first time and they hear frustrated people all day. Tell them you are frustrated, but remain calm.
5. If you have a critical illness- many of the major insurance companies have critical illness programs that are not necessarily advertised – they will find you eventually via the claim trail- that do offer other ways to help you. Also, hospital social workers are a wealth of information in helping find ways to reduce copays for medications if that is an issue.
6. If you cannot make nice with the insurance company- then ask whoever you are on the phone with how to file a formal complaint with the insurance company. Repeat yourself/ask the supervisor until you are told how to do that.
7. If that does not work, or you have questions at any time about managed care, then call the managed care board
HMO:
http://www.dmhc.ca.gov/dmhc_consumer/pc/pc_default.asp
Medical:
http://www.opa.ca.gov/healthcare/problems/medi-cal-complaints.aspx
Consumer Advocate Medical Care: