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Insurance: Do you know what you need to know?
"I have
MS, and we are assigned levels of severity. Insurance denies medical
prescriptions because it is not for my assigned level. The physician
thought it was the right thing to address my current needs, yet
I cannot have it because the insurance company says no."
"In order
to have physical therapy, we need to show physical progress to
continue. That doesn't happen with chronic disease - therapy helps
you maintain function. Insurance companies need to realize that
maintenance can be more important than improvement."
"I have
an education and want to work, but the problem of pre-existing
conditions and losing my Medicare keeps me home and on assistance."
- Women
with Disabilities in North Carolina: Their Views on Health Care,
NC Office on Disability and Health
People
with disabilities often have health care needs that vary in type
and intensity over time. The challenge for you, as a consumer, is
to find a health care plan that best meets your needs. This requires
understanding how the health insurance that you choose will work
for you and your family members.
Medicare,
Medicaid, Worker's Comp, an HMO, PPO, or traditional health plans
all come with a policy. Some plans are traditional fee-for-service
programs with few restrictions on choice of doctors, while some
are preferred provider organizations (PPOs) that require the equipment
or treatment to come from specified providers. Others are health
maintenance organizations (HMOs) that restrict your choice of providers.
With
the various insurance plans, some rules you're likely to encounter
may include:
- Required
letters of medical necessity
- Required
pre-approval, exclusion of certain equipment
- Yearly deductibles
(the amount of money you have to pay before insurance will cover
costs)
- Limits on
care provided out-of-state
It's
important to know the rules ahead of time in order to choose the
best plan for you. And as one savvy consumer put it, "Don't expect
Cadillac coverage from a Chevy policy." Do your homework and know
what your policy covers.
One
claims representative emphasized that policies have rules. "We don't
buy sports chairs; we don't buy multiple chairs; we don't buy hearing
aids; we don't buy vans; we're not liable for quality of life things.
Our guidelines clearly state that equipment must address functional
capacity and activity of daily living."
Choosing Health Insurance
When
choosing a health insurance plan, consider the following questions:
- Are pre-existing
conditions covered?
- Do I need
to choose a primary provider to coordinate my care, or can I obtain
care from any provider?
- How will
the health plan treat my health condition? What are the plan's
clinical protocols regarding the treatment of my particular condition?
- Can I go
outside of the health plan network to seek care from a non-network
provider?
- Will I have
to pay a co-payment or deductible for visits to my provider? For
tests? How much?
- Will the
plan pay for the prescription drugs I need?
- If I need
care in a hospital, which one does the plan use? How much of the
cost is covered?
- Can I see
a specialist when needed? How do I do that?
- Does the
plan cover allied services like therapies?
- Does the
plan cover medical equipment, medical supplies, orthotics, prosthetics
and assistive technology?
- If I have
a problem with the plan, what is the process for handling my complaint?
Appeals
Denials
Richard
Holicky, writing in the March 2000 issue of New Mobility, said,
"Medical insurance, regardless of who provides it, can be a source
of stress. Most of us have been there, trying to deal with the logic
of being denied a shower/commode chair because it's not 'medically
necessary'. It's a jungle out there, and what once was the domain
of medically trained and knowledgeable personnel is now the dominion
of bean counters entrusted with cost containment."
Many
decision-makers are far more focused on dollars and cents and medical
necessity than on active living or quality of life. That replacement
chair or backup ventilator that's a top priority to you may seem
like a frivolous convenience to a case manager holding the bottom
line.
"Form
letters just don't work anymore," according to a hospital counselor
who advocates for patients. What gets funded is dependent on the
wording of the policy and the wording of the requests. People are
usually more successful if they use medical terms to justify their
requests. "getting out of bed" becomes "skilled transfer" or "posture
positioning," when a "bowel program" becomes "administering of medications
(suppositories)," when "bathing" becomes "monitoring for skin integrity,"
case managers tend to be more receptive, the counselor said.
Another
valuable tactic is to point out the long-term prevention aspects
of both care and equipment. For example, explain the cost of skin-flap
surgery when requesting a replacement cushion. Work with your provider
to write a letter of medical necessity for what you need.
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Once
you understand that a denial is simply a business transaction,
you won't let it discourage you. Keep a key statistic in mind:
70 percent of denials are never appealed. And it's likely
for things out of the ordinary to be denied after the first
claim.
No
matter whom you talk to, one piece of advice always comes
through loud and clear: always appeal denials. And if you
feel you're on sound footing, don't stop with simple appeals
to the insurance company. You have other options. Write letters;
make phone calls; put your tax dollars, public employees,
and elected representatives to work. Write your state insurance
commissioner. Exhaust all avenues.
Say
it with me: "Always appeal denials."
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Annette
Lauber with the NC Assistive Technology Program offered these
survival tips:
- Policies
are different. Know your policy, its limits, inclusions,
and exclusions. Make sure you know if you have a fee-for-service
or HMO plan.
- Justify
and document the medical necessity of all requests.
- Be
polite and businesslike, and don't take denials personally.
- If
your claim is denied, find out why it was denied; then appeal
it. Include letters of medical necessity from your provider.
- It
is not unlikely for things out of the ordinary to be denied
after the first claim.
- Refer
to your insurance benefits materials, which will outline
the appeal process
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[By
Richard Holicky, health counselor and free lance writer, excerpted
from "Insurance Tips," in New Mobility magazine, March 2000. ]
Health
Insurance Resources ...
American
Association of Retired People
(AARP)
www.aarp.org
An Overview of Managed Care at http://www.aarphealthcare.com/Learn/ManagedCareOverview.aspx
Independent
Living Research Utilization
http://www.ilru.org/
Centers
for Medicare & Medicaid Services (formerly HCFA): The Medicare,
Medicaid, and SCHIP Agency
http://www.cms.hhs.gov/
NC
Institute of Medicine
Go to the link, "Questions to Ask Your Plan: People with Special
Health Needs" at www.nciom.org/hmoconguide/GENDIS.html
See
also ...
Educate
Your Doctor
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