Thursday, January 03, 2008

How to Challenge an HMO's Denial of Coverage
"It's not unusual for a health maintenance organization, or HMO, to deny a treatment or test. When this happens, it's worth the effort to fight back."
Step One Enlist your primary care physician (PCP) in your fight. In many cases, he or she is the gatekeeper to medical services.
Step Two Start a logbook to document every telephone communication with your HMO and doctors.
Step Three Include in your logbook the name, number and address of the person you talked with, the date and time of the phone call, who initiated the call, and what was said.
Step Four Make it clear to every person on the phone that you're keeping a log.
Step Five Follow up the most important phone calls with written letters recapping what was said. Send CC copies of these letters to your PCP and your attorney, if you have one.
Step Six Keep copies of all correspondence you send and receive. Note the date that you received the mail, and keep the postmarked envelope if you believe the date may be relevant.
Step Seven Take careful notes in all face-to-face meetings with doctors. Make it obvious - use a large pad of paper and write your notes contemporaneously (not afterward from memory).
Step Eight Consider tape recording phone conversations and medical meetings.
Step Nine Enlist the help of your congressional and state representatives.
Step Ten Contact an attorney who specializes in medical matters, if all else fails.
Tips & Warnings
* Make sure your physician uses the phrase "medically necessary" when referring to the treatment you need.
* HMOs are regulated by your state's department of insurance.
* It's illegal to tape a conversation without the other party's permission. Be sure to ask.

Your Guide to the Appeal Process... Patient Advocate Foundation
"This easy to read guide features sample appeals letters, specific strategies to use when negotiating the internal and external appeals processes and specific instructions to follow when all appeals have been exhausted and it's time for the next step." Contents
Step 1: Gather Preliminary Information
Step 2: Understand the Illness and the Insurance
Step 3: Write the Appeal Letters
Step 4: Evaluate the Result
Step 5: When to Consult an Attorney

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