The Wall Street Journal - July 8, 1996
Marilyn Chase

What do you do when your insurer or health plan writes a prescription -- either for planned treatment or for reimbursement after care -- that's different from what you had in mind? Experts offer strategies that can bring you closer to getting what you want.

Enrollees in any health plan -- whether it's a fee-for-service insurance policy, a government plan or a managed-care group -- need to know the plan's rules and limits. Keep records and dated correspondence, and know the billing codes for the treatment in question.

Numerous problems arise from "simple miscoding" of the medical procedures in the claim, says Carol Jimenez, attorney for the Los Angeles-based Center for Health Care Rights, a nonprofit consumer advocacy group.

Typical is the case of a 30-year-old Los Angeles woman who got a mammogram to investigate a breast lump. Payment was denied three times. Finally, she discovered her doctor had miscoded the procedure as a routine screening (which wasn't covered for a woman her age) rather than a test to explore the lump. Once clarified, the claim was promptly paid.

"First call the plan's customer-service number and find out why a claim is denied," says Ms. Jimenez. "There may have been a clerical error by the doctor or hospital. Talk to the source of the inaccuracy."

Don't take `no' for an answer, experts say; up to half of some claims initially rejected are paid upon review. Study the explanation of benefits and return it with a note asking for more reimbursement, or requesting peer review.

IF AN IMPASSE seems insurmountable, file a complaint with the state regulatory agency -- usually the Department of Insurance. For complaints against HMOs in some states (like California), you file with the Department of Corporations.

"You have to document everything. You have to be prepared to be a tremendous letter-writer," says Eleanor Hamburger, an attorney with Consumers Union in San Francisco. "Be aggressive, but cool and levelheaded."

She also notes that when a doctor discourages your treatment preferences, it doesn't necessarily mean a flat denial. "Go back [to the physician] and say, `I'm making a formal request. Are you really denying me this?'" she says. Ask the doctor whether the denial is medically or financially based. If the plan rewards doctors for limiting care, remind them they may be liable.

If you file a complaint or grievance against an HMO, inform the plan explicitly. Inquire about who handles grievances -- the HMO or the medical group with which it contracts. Ask whether you can appear in person to make your case and whether you can bring a lawyer, friend or doctor with you.

Adhere to deadlines and insist that your plan do so. Lengthy arbitration claims sometimes outlive the patient.

Also, insist that claim reviewers be expert and neutral, advocates say. "Find out the credentials of the people reviewing your claim. If it's a neurosurgery claim, it should be reviewed by a neurosurgeon, and not a teeny-bopper in the back room or someone who doesn't practice medicine anymore," says Grace Powers Monaco of the Medical Care Ombudsman Program in Bethesda, Md., a group providing independent medical review that's free to patients.

"Know the basis of your claim, and ask for citations from the medical literature," she advises. If the plan excludes a new treatment, ask whether coverage can be updated.

She says in one case her group handled, new information awaiting publication was obtained and used to persuade a plan to cover a particular kind of tumor treatment.

WHEN INSURANCE companies deny a charge as exceeding what's "reasonable and customary," patients can get a supporting letter from their physician, or seek support from several doctors in their geographic area. County medical associations will sometimes review your charge and tell you whether they consider it reasonable and customary, says Daniel Fiduccia, an advocate for people with cancer and disabilities, in Cupertino, Calif.

Patient support groups and advocacy organizations associated with particular diseases offer both moral support and practical advice on how to negotiate with health plans.

At age 57, Mark Braly of Sacramento, Calif., battled several insurers during his prostate-cancer treatment before stumbling onto a support group at the University of California at Davis. He says he wishes he'd found the group sooner.

"It arms you to ask the questions to find the information you need," Mr. Braly says.

The National Coalition for Cancer Survivorship in Silver Spring, Md., offers tips for filing cancer insurance claims -- for example, it tells you claims for items like chemo-wigs require a copy of the prescription in addition to the bill.

AIDS Treatment Data Network in New York City launched its Access Project to build a database on insurance coverage and patient-assistance plans. Project Director Richard Jefferys found an unexpected ally in the drug companies.

"The great majority of AIDS-drug companies have reimbursement-assistance programs," he says. "It's in their interest to make sure there's coverage somewhere before they give [the drug] to you for free."

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