How To Maximize Use Of An HMO And Other Managed Care Policies
- Studies show that patients do better if they are active in their care.
- In addition, HMOs are often referred to as managed cost instead of managed care. It's your job to assure that the care is what you need, when you need it.
- If you have your insurance through a group, talk with the person at the group in charge of insurance for practical information about the policy and how best to use it. If you make a friend of the person, you'll have someone to call if you ultimately need a person of influence to help you change an insurance company "no" to a "yes."
- Find out if your plan has an advice hotline. Some plans have toll-free phone services that help members decide how to handle a medical problem that may not require a doctor's visit. If a problem relates to any symptoms you've been alerted to watch for with respect to your diagnosis -- go directly to the doctor.
- Remember: You have ultimate control over your treatment, even in an HMO.
Learn about your plan. Know what you're entitled to instead of relying on someone who isn't as interested in your health as you are to tell you.
- HMO coverage varies widely. Your benefits may even differ from those of other members of your HMO. This could be because your employer decided to pay for different benefits. Or, if you are an individual or a Medicare member, you may have different coverage from employer group members. Read your health insurance policy and member handbook. .Sales materials or plan summaries won't give you the full picture.
- Learn about:
- Benefits (To learn more, see: Benefits Provided By An HMO)
- What your plan covers and doesn't cover
- How your plan works. For example, how do you get permission to see a specialist, get a lab test or go to a hospital of choice? Especially focus on steps you may have to take before you take a medical step. Also note the days you have after receiving a service to submit a claim.
- How you will be kept up-to-date about changes in doctors and facilities that are part of the network.
- Ask if your plan has a magazine or newsletter. If, it is worthwhile to be on the mailing list. These publications are a good source of information on how the plan works and other useful information.
Choose a Primary Care Physician (PCP) with care. Get to know the PCP and about potential conflicts of interest. Learn how to get what you need from a PCP.
- One of the most important aspects of maximizing use of an HMO is to choose a Primary Care Physician with care.
- Get to know your doctor.
- Learn how to get what you need from him or her.
- For information about how to choose a primary care doctor, click here.
Learn how to maximize use of your Primary Care Physician. For information, click here.
Choose specialists like an educated consumer.
- Studies show that people do better with serious health conditions if they have qualified specialists who are experienced with their situation.
- For information about how to choose a specialist, click here.
Use in network doctors and other health care providers as much as possible.
- People and companies that contract with an HMO come and go. If you find the name of a provider in the HMO's booklet, confirm with the doctor's office before setting an appointment that theperson is still contracted with the HMO.
- When setting a procedure with an in-network doctor who will also need other doctors as part of the procedure (for example, with surgery where an anesthesiologist will be present), ask that all doctors involved with your care be in network doctors unless an emergency occurs and an in-network doctor or facility is not available.
- When entering a hospital, it is advisable to let the intake person know you have a policy that requires in-network doctors and that you only want to see in-network doctors unless an emergency requires seeing another doctor.
- When in a hospital, consider posting a sign over your bed with the name of your insurance carrier, and that only doctors who are in network should see you.
- If you unknowingly use team members that are not part of your plan, appeal if the insurer refuses to pay.
If you want to use out of net work doctors and other health care providers, learn how to minimize the amount you have to pay
- There are a variety of techniques to help minimize the amount you have to pay when you go out of network. Because of the amount of information, this subject is covered in a separate article. To learn more, click here.
Connect with case management.
- Most HMOs maintain a staff of medical case managers, whose job is to help coordinate the care of members with chronic or life-challenging conditions. Case managers are usually nurses or other medically trained personnel.
- Case Managers can be an important medical ally. To understand how, and to maximize use of a case manager, click here
If you think you need a second opinion, ask for one.
- Also consider asking for a second opinion if you get bad news -- or very good news. To learn more, see: When do you need a Second Opinion.
- To find the best doctor for a second opinion, see: How To Choose A Doctor For A Second Opinion.
- If you don't think there is a doctor in the network best qualified to give a second opinion, or the doctor is not likely to be independent, ask for permission to get a second opinion form a doctor who is not in the HMO's network. If the request is refused, see: Health Insurance: Claims: Appeals: Sample Letter: Second Opinion.
Take advantage of the mental health coverage in your plan.
- You can always discontinue if it's not helpful.
- Your mental health is as important as your physical health. It can be argued to be even more important in the sense that it is your mental health that helps drive your obtaining the best medical care and adhering to ongoing drug schedules.
- A mental health provider can help keep depression and anxiety in check.
- If you ultimately decide you want to stop work and go onto disability, mental health can be part of a disability determination. In fact, a mental condition such as depression can in itself be considered to be a disabling condition. For information about applying for Social Security Disability Insurance (SSDI), click here.
Learn what to do in the event of a medical emergency.
- Emergency room treatment is usually covered wherever you are in the United States.
- Many HMOs discourage emergency room treatment by requiring members to call and obtain approval before going to an emergency room. The only exception allowed is if you have symptoms that are either life-threatening or would seriously impair your health if not treated immediately. Thanks to the Pruden Layperson Rule, if a person believes that he or she is so sick that a trip to the emergency room is necessary, an HMO has to pay for the visit even if there was no call for prior approval.
- If you do try to call the insurance company, but cannot get through in an hour, thanks to NCQA, you may receive treatment in the ER without any authorization. Please keep in mind that proving that you couldn't get through to the HMO for more than an hour can be difficult.
- If you have a question about whether a condition requires you to go to the emergency room, call your doctor's office immediately.
- If you go to an emergency room, as soon as possible, contact your primary care doctor and health plan and let them know. The insurance company needs to know to be sure you're covered. The doctor needs to know to provide ongoing care.
- If you go to an emergency room while traveling, the facility may require immediate payment. Get a complete statement of the services provided to you. If possible, also get a copy of the emergency room report. When you get home, call member services at your plan to find out how to submit a claim.
When a drug is prescribed, look for the alternative that is on the HMO's formulary and that has the least out-of-pocket expense.
- HMOs only cover drugs that are on the plan's formulary.
- If a prescribed drug is not on the HMO formulary, ask whether there are any drugs on the formulary that would work just as well.
- If the drug is on the formulary, heck to see what co-pay is involved. Most health plans have lists in tiers, with different co-payment for each tier. If the co-pay is high, ask your doctor if there are other drugs on the formulary with a lower co-pay that will work as well.
- If you have HIV, ADAP may cover your medications even though you have health insurance. Call AIDS Treatment Data Network at 212.260.8868 for your state's ADAP number, or look it up at www.atdn.org/access/states? If your income is too high to qualify, a tax expert can often help you work it out so your taxable income qualifies you for ADAP next year.
Learn what to do if a drug or treatment you want is denied or if you have other complaints against the Insurer.
- Appeal if you want a drug or treatment or to see a Specialist, and your request is denied. To learn how, click here.
- Be persistent. Experience shows that persistence pays off.
- If appeals within the HMO don't succeed, explore external appeals.
- If you still don't get what you want, consider complaining to the regulators, consumer organizations and the press and/or going to court or arbitration.
- If you encounter other problems, file a grievance.
Get help dealing with the insurance company if you need it.
- If you do not believe you are capable of dealing with the insurance company to get what you need, ask someone to do it for you. For example, a friend who is knowledgeable about dealing with insurance companies, or a social worker that your doctor's office can recommend or a financial planner.
- Expect that the insurance company will insist on your filing a form authorizing the person to contact the company on your behalf.
Carry your i.d. card with you in your wallet or purse.
- Your i.d. card identifies you as insured. It may also state the amount of your deductible, co-pay and/or co-insurance.
- The card likely also includes an 800 number in case you need to speak with your insurer.
- You'll need the information each time you see a new health care provider. It will also be available in case of emergencies.
If you want to change health plans, learn how to keep your doctor. Alternatives to consider include the following:
- Ask your doctor if he or she will join the new plan. If the doctor will join the new plan, you're set. If not, find out why. The doctor's reason(s) may give you insight into your new plan.
- Check to see if the plan has a provision about "continuity of care" under which you have a right to continue to see your doctor for a period of time -- such as ninety (90) days -- or until the doctor certifies it is safe to transfer you to a new doctor.
- Check your state law. Even though there is nothing stated in your policy, you may have the right to stay with an out-of-plan doctor, at least for a period of time. To learn about the law in your state, see: www.healthinsuranceinfo.net . To find the contact information for your state's insurance department, see: www.naic.org.
Keep in mind that insurance policies are not set in stone - negotiate.
- Insurance policies are not set in stone. You can negotiate.
- If you can show that what you want is reasonable, medically necessary, and can save the the insurer money, you have a chance of getting what you want. Speak with a person in authority who can make a decision. If you have a case manager, she or he can help. Also consider bringing in someone to negotiate for you.
If you don't get what you want, appeal. Appeal. And keep appealing.
- Statistics show that appealing is in your interest. The higher the level of appeal, the more likely you are to win.
- Appeals do not have to be expensive.
- To learn about, the following, click on the link.
To Learn More
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