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Ten tips

Best ways to handle health plan disputes

By LAURA T. COFFEY
Published August 28, 2005

If you have health coverage, you'll likely receive the medical care you seek. But that doesn't mean your health plan will necessarily reimburse you for it. Payments often are denied for treatments that are new, experimental or not deemed medically necessary. Denials also can happen in routine situations. Here's how to proceed if a dispute arises:

1. READ THE FINE PRINT FIRST. Before you go see a doctor or specialist, review your health plan's rules to see what the plan will and will not cover. Certain aspects of the rules may be very clear.

2. TRY CUSTOMER SERVICE. If your claim is denied or not paid in full, call your health plan and ask why. It might have been due to an administrative error. Have all your paperwork in front of you when you make the call.

3. DOCUMENT ALL CORRESPONDENCE. From the moment you call customer service about your situation, start keeping a careful record of each phone conversation and letter exchanged between you and your health plan. You may need it later.

4. CONSIDER REQUESTING A FORMAL REVIEW. If customer service doesn't help you, you can file an appeal with your health plan. In most cases, you must do this in writing within 60 days of receiving the original explanation of benefits. Send your appeal via certified mail.

5. EXAMINE DOCUMENTS CAREFULLY. If you launch such a formal review, you may be given access to all the documentation used to determine your benefits. Don't be too surprised if you discover an error that could change a denial to full payment.

6. QUESTION RATES THAT SEEM UNREASONABLE. Most health plans will tell you their fee schedules are not subject to change, but if it seems obvious that a certain reimbursement is especially miserly, call and question it. Most insurers will investigate large discrepancies, and on occasion they will make changes.

7. YOU CAN FILE A COMPLAINT. If your health plan won't help you at all, you may need to alert regulators to your situation. To file a complaint with the state Office of Insurance Regulation, visit the Florida Department of Financial Services' Web site at www.fldfs.com or call toll-free 1-800-342-2762.

8. KNOW WHEN TO PURSUE AN OUTSIDE REVIEW. If your insurer denies your claim on the grounds that a treatment is not medically necessary and you strongly disagree with that decision, you can request a review by an outside panel of regulators and physicians. Such panels overrule health plans' decisions in about half of all cases.

9. KNOW THE ROPES. You must go through the internal appeals process described above before you can ask for an external review through the state Agency for Health Care Administration's Subscriber Assistance Program. Visit www.fdhc.state.fl.us/MCHQ/Consumer/SPSAP/index.shtml or call toll-free 1-888-419-3456.

10. CONTACT THE FEDS. Many large employers provide self-funded health plans, in which the employer pays workers' claims. Because such plans are not regulated by the state, you must file complaints with the U.S. Department of Labor's Employee Benefits Security Administration by calling toll-free 1-866-444-3272 (EBSA).

Sources: Kaiser Family Foundation (www.kff.org/consumerguide/7350.cfm) Consumers Union (www.consumersunion.org) SmartMoney Magazine (www.smartmoney.com)

[Last modified August 24, 2005, 20:07:03]