If the phrase “managed care” evokes a sense of dread for you, you’re not alone. But consider yourself lucky. One in five Californians isn’t even covered by the health-care system, according to a recent Kaiser Family Foundation report.
Once you get into the system, navigating it can be daunting. Whether you’re choosing health care, using your benefits, or trying to stay healthy so you don’t have to use them, the best thing you can do is to be proactive. Ask the right questions, know your benefits, and know your rights — and, if necessary, be prepared to fight for them.
Get Yourself Insured
A lot of people don’t really “shop” for health insurance — they’re offered a choice of plans through an employer and asked to choose one. If there’s a choice, it’s often between an HMO and a PPO. For those shopping for insurance on their own, a reputable insurance broker may be the best bet. “A broker can help guide you through the insurance options and it won’t cost you any more than if you went to the insurance company yourself,” says Gina Stassi, senior director of products and marketing for Blue Shield of California.
Before you even sit down to look at your health-care options, you should do an individual “needs assessment,” says Earl Lui, a senior attorney in the West Coast office of the Consumers Union. Consider any medical conditions you have, drugs you take regularly, your family situation. Take all of this into account and then sit down and read the fine print. Plans vary widely in terms of coverage. Where premiums are very low, look out for high copays, deductibles, and low coverage limits.
If you’re approaching health care with your bank account in mind, “HMO coverage is certainly the best value for the dollar,” says Darryl Cardoza, chief operating officer for Hill Physicians Medical Group, the largest independent practice association in Northern California. “HMO plans offer the most comprehensive scope of benefits and the lowest out-of-pocket costs of any type of health plan out there, but the problem with them is that because they offer comprehensive benefits that are actually prescribed by law, there’s not much flexibility in narrowing that and so premiums are getting more and more expensive.”
PPO plans do have the flexibility to offer a more limited set of benefits, since they’re not governed by the same laws as HMOs. So sometimes they can look less expensive on paper, says Cardoza. But buyer beware — what you save on the premium you may pay ten times over in copays and deductibles.
There’s also a new type of health-care plan that’s entered the market within the past few years — the consumer-driven plan. The idea is that you or your employer subscribes to a plan that lets you put money into a savings account to use however you choose. If you don’t incur a lot of health-care costs throughout the year, all that money you save rolls over to the next year in your account. If a catastrophic medical situation arises, the plan has backup insurance that kicks in at a certain point (usually after you’ve spent at least a few grand on the incident).
Most consumer groups have come out against these plans because of their potential impact on overall health-care finances. But individual consumers do have the opportunity to save bundles if they stay healthy.
“If you’re willing to make a bet that within the next year you’re not going to need much health care, or if you have a lot of money and aren’t worried about how much you might have to spend, then a consumer-driven plan might be for you,” Cardoza says. “These plans are really for the healthy and the wealthy.”
Discount health cards are another category altogether. These programs are often advertised as if they are actually health insurance. They aren’t, and consumer groups and the California Department of Managed Health Care are working to make sure the public understands that. Most of the discount programs charge a monthly fee for a card that supposedly gives discounts on doctors’ visits and other health-care services.
“Health-care discount cards are a scam,” says the Consumers Union’s Lui. “If you’re paying out of pocket for your health care, you can just ask for a discount. You don’t have to pay a third party and carry a card to get one.” He advises patients without insurance to be sure to ask about charity care, payment plans, and discounts for cash when paying for a doctor or hospital visit. Discounts are often available, but aren’t offered unless you ask. And do shop around — different insurers often charge different rates for the same person.
Keep Yourself Insured
Over the past six years, Maura Carley has worked with many individuals who didn’t understand their health coverage — or lack thereof — and learned the hard way through a medical crisis. With a master’s degree in public health and 25 years of experience as a top executive at Kaiser Permanente, Yale-New Haven, and Stamford hospitals, Carley started her “boutique business,” Healthcare Navigation, in 1999 to fill a niche she saw throughout her years of work in the field. The Connecticut-based company has assisted clients all over the country with medical billing problems, denials of coverage, and various other health-care issues. Carley has helped some people recoup thousands of dollars in medical overcharges and others convince their insurance companies to pay for life-saving medical treatments.
“I’ve seen so many tragic cases over the years,” she says. “Situations where people just assumed that their coverage was in place, when in reality a lapse had occurred or restrictions that they weren’t aware of existed.”
Some of the most important things to understand are not only the limits and fine points of your health coverage, but also the following big picture issues, says Carley.
Avoid gaps in coverage, because once you obtain coverage again, the gap allows the new insurer to impose “pre-existing condition exclusions” for a period of time, and can exclude or refuse to pay for services associated with an illness or disability you already had.
Understand that pre-existing conditions can prevent you from buying individual private health-care coverage in most states. There may be a “high-risk pool” you can join to get coverage, but this may be very limited, expensive, or both. State programs vary widely. “This is a terrible, disgraceful, and perhaps immoral problem in our wealthy country,” Carley says, “but understanding this issue may help prevent you from being a victim of this injustice.”
Remember that life transitions — your own, or those of a person to whom your health care is connected — can affect your coverage. Carley gives the example of a college student who changes from full-time to part-time, without realizing that his father’s health insurance covers him only if he’s full-time. A divorce can be particularly perilous for a husband or wife whose coverage has long been tied to their spouse’s employment. Coverage through an employer can be extended through COBRA, but this is temporary and consumers must plan for the next step.
Make Good Medical Choices
If you’ve joined an HMO, your next step is usually choosing a primary-care doctor to be your first point of contact for all your medical needs. You can ask friends and colleagues for recommendations, but ultimately the best choice for you might be different than what’s best for them.
Start with your insurance plan’s Web site — most offer a feature that lets you search for doctors by location or other criteria. Some insurers also provide this service via phone.
After you’ve narrowed the list down to perhaps three or four doctors, call to schedule an interview appointment, says Charles Inlander, president of the People’s Medical Society, a 23-year-old consumer advocacy organization. Be prepared to ask whether your doctor’s opinions are on a par with yours — does he or she support taking herbs and vitamins, if that’s part of your regimen? If you’re admitted to the hospital, will your doctor check in on you there (a lot won’t)? Does your doctor ask you questions? Does he or she interrupt you?
If you’re part of an HMO, you may feel that you have little choice beyond your primary-care doctor. That’s not true. If you know you’ll need a referral, you can walk into your doctor’s office with the name of a specialist on your plan whom you want to see. If you don’t like the specialist your doctor refers you to, you can ask for another referral, advises Hill Physicians’ Cardoza. You’re also entitled to a second opinion from a different specialist.
And if the doctor you want to see is in a different medical group than the one you’ve selected, Cardoza says, you can switch groups at the beginning of the month. You’d have to also change your primary-care doctor to one in the new group, but if you have a special need it might be worth it.
Managing a Medical Diagnosis
When your doctor hands you a diagnosis, whether it’s an acute or chronic condition, “the first thing a savvy medical consumer does is to ask questions and say no to things that they don’t understand,” Inlander says. “Medicine is an evidence-based field, and you should be given the evidence to support why you’re being told to take a medication or undergo a certain procedure.” If you feel that you can’t be assertive and ask the questions you want answered, take someone with you to your medical appointment who will do it for you, Inlander advises.
The national nonprofit organization Partnership for Clear Health Communication advises all patients given a diagnosis to be sure they understand the answers to these three questions: What is my main problem? What do I need to do? Why is it important for me to do this? If your doctor can’t answer these in language you understand, ask again.
The next step is to seek a second opinion. Inlander cites the example of a friend who was experiencing shortness of breath and received three different diagnoses from three different doctors. In these kinds of cases, seek consensus, Inlander advises. It can be disconcerting when the best treatment option is not clear-cut, but in the end you’re doing yourself a favor by seeking out all opinions.
Do your own research on your specific condition — know about the treatment options that are out there, Inlander says. Go online to do your research, but be careful to look at whether the medical sites you’re visiting are actually sponsored by a group with an ulterior motive — for instance, a drug company. Then take what you’ve found and ask your doctor about the options. Or call a number of medical centers and ask for the top doctors in your specialty area — see if you can have a phone consultation to ask what they think of treatment options for your condition.
“If a doctor balks at your questions, find another one,” Inlander says. “A good doctor will inform you of your alternatives and educate you about why he thinks one option is your best one.”
While there’s little you can do to prepare for a medical emergency, Inlander advises setting up a living will and having it in an easily accessible place. Have a designated medical power of attorney, so that you can have someone you trust to make medical decisions for you if you’re unable to. And make sure that all the medications you take and the doctors who treat you are listed on a piece of paper in your wallet — the first place a emergency medical technician will check for vital information.
Know Your Rights
When you’re faced with a denial of coverage, rule number one should be to file an appeal, says the Consumers Union’s Lui. Usually there are instructions for this on your health insurance statement. Call your doctor for advice — perhaps to have him or her write a letter on your behalf. Next, go to a government agency — if you’re with an HMO in California, that would be the Department of Managed Healthcare. You can also call the department for advice about appealing a claim before even filing paperwork.
If you have a PPO, then the Department of Insurance regulates your policy provider. Unfortunately, that department is not as consumer-friendly, says Lui.
Mara Rothman, director of customer service for Athena Feminine Technologies, a medical device company based in Orinda, had little experience dealing with the health-insurance system until she started working at Athena. These days, she spends much of her time on the phone with insurance representatives trying to get patients’ insurers to cover Athena’s product, an FDA-approved medical device for women with incontinence. “The most important thing when dealing with health insurance companies is don’t give in and don’t give up,” she says. “Pushing is the only way to get anywhere.”
If you hit a wall, Rothman recommends turning to California’s Office of the Patient Advocate. “I’ve worked with them a couple of times and have been really impressed,” she says. “They review denials of coverage from HMOs and if they decide that your HMO has to cover something, then they’re legally required to.”
If you can show that the treatment you need has never been done by any doctor in your HMO, or that there’s another doctor out there who successfully treats your condition all the time, a lot of times HMOs will pay for it, Inlander says. In the long run, it’s cheaper to be treated by an experienced doctor than to stay in network. “It’s difficult, but you just have to be aggressive in filing your appeal,” he says. “Over the years, managed care has become much more liberal about this, and it’s a lot more common than it used to be.”
If you get a bill when you think insurance should have paid, follow up quickly to resolve the problem. Keep good records, file an appeal if appropriate, and don’t let a dispute go to collection because then it’s even more difficult to resolve, says Healthcare Navigation’s Marley.
Resources
The California Department
of Managed Health Care
888-466-2219
The Department of Managed Health Care regulates all HMOs in California, including Medicare plans. If you need help resolving a problem with your HMO, you can contact the department. It offers an independent medical review program that allows you to request an impartial review of HMO decisions concerning the medical necessity of a proposed treatment, experimental or investigational therapies for certain medical conditions, or denied claims for out-of-plan emergency or urgent medical services.
Office of the Patient Advocate
California has its own Office of the Patient Advocate, an independent office in state government charged with informing and educating consumers about their rights and responsibilities as HMO enrollees. It is required to publish an annual Internet-based report card on the quality of HMO services, develop consumer education materials and programs, advise the Department of Managed Health Care regarding consumer issues, and collaborate with government- and community-based patient-advocacy organizations.
Consumers Union
The nonprofit organization, publisher of Consumer Reports, offers independent reports on health-care topics, including a guide to choosing a health-care plan.
The Berkeley Parents Network
This popular East Bay e-mail group also has a Web site with a long list of referrals and recommendations for area doctors and practitioners.
The California HealthCare Foundation
An independent philanthropy that offers a list of consumer resources to help specific groups assess and compare their coverage options.
The Patient Advocate Foundation
A national nonprofit organization that provides professional mediation to help patients ensure access to care. Its Web site includes a plethora of resources, including a guide to choosing your health-care plan and to filing an appeal.
Coalition Against Insurance Fraud
Alta Bates Medical Group
Hill Physicians Medical Group
Citizens for the Right to Know
A network of consumer and specific disease organizations offering guidelines for choosing health care and news and information about health care and HMOs. The site includes articles like “Five Medical Tests Worth Paying For” and “Healthcare Decisions During Open Enrollment.”
The People’s Medical Society
A nonprofit dedicated to educating consumers about health care and medical rights. It has also published and sold seven million copies of a variety of consumer-oriented titles such as Take This Book to the Hospital with You and Getting the Most for Your Medical Dollar.
WebMD
A good general starting point for researching medical conditions.
Kaiser Permanente
Kaiser’s site offers a lot of medical information; its preventive care and health education classes are often open to members and nonmembers.
