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Mary Koluski of Wallingford, Conn., is finally free of the excruciating headaches that plagued her for 28 years, thanks to injections of botulinum toxin type A (Botox). She recently learned, though, that her insurer would no longer pay for the doctor visits that are a necessary prerequisite for the treatments.
“They can't give me the injections without the medical update and to check up on my meds,” says Koluski, a 50-year-old music instructor.
Her neurologist, Alan Rapoport, M.D., of the New England Center for Headache in Stamford, Conn., submitted a statement to her insurer, explaining why she needs the check-ups prior to the treatments she receives every 10 weeks. Now Koluski is waiting for a hearing date she hopes will resolve the dispute.
Koluski is not alone. An estimated 16 million Americans are underinsured — that is, they have health insurance but their plans either lack some types of coverage, or have high deductibles, according to a study by the nonprofit health policy foundation, the Commonwealth Fund, published in Health Affairs magazine this summer. Forty-six percent of those who were underinsured said they went without care because of the costs. That's on top of the 45 million Americans — or 15.6 percent of the population — who don't have any health insurance, according to U.S. census data.
Often, people assume their health insurance plan is adequate, only to learn later on that their doctor-recommended treatment or procedure is not covered. That's what happened to Angela Haasl, 25, of Minneapolis, Minn., a cost estimator for Habitat for Humanity, an international nonprofit organization. She knew her insurance covered the basics, including physicals, but was unaware that it would not pay for blood tests. She subsequently received a $2,000 bill for lab tests that she could not afford to pay.
Calls to her health maintenance organization (HMO) finance and patient-relations staff were fruitless. “There seems to be a huge disconnect between insurance companies and providers,” says Haasl, and patients are caught in the middle.
Recently her doctor recommended that she get a diagnostic ultrasound because he suspected Haasl might have a blood clot in her leg. This time Haasl asked specifically whether her insurance covered the test. “The doctor said yes, but the insurance company said no.” Haasl ended up paying $200 for the ultrasound test.
But Haasl still could not pay the $2,000 bill for lab tests. She found help through the Health Care Help Line, a service available to constituents of Minnesota Senator Mark Dayton. Marija Knudson, the program's director, agreed to intervene. Working with the HMO patient-relations staff, she asked that their primary caregiver review the bill and determine if the tests were necessary. She also suggested that some billed items might be coded differently so they would be more likely to be covered by the insurer.
“After the changes were submitted, my insurance agreed to pay $1,300 of the $2,000 bill. The hospital dropped the rest of the charges,” said Haasl. Her final out-of-pocket expense for the physical was reduced to $300.
Other states may not have full-fledged programs like this one, but congressional representatives often designate staff to help find medical resources for their constituents, so don't hesitate to call upon your elected officials for help. You can find out how to contact your representative by clicking on www.house.gov .
When your doctor orders a test or treatment that isn't covered, you may have to pay for it yourself.
“This is a common problem for all of us,” says Randolph Evans, M.D., a neurologist in private practice in Houston, Texas. He cited high plan deductibles and co-pays as disincentives for some patients to get the tests their physicians recommend as part of a diagnosis. “It has become an obstacle” to patient care, says Dr. Evans.
If you believe your insurance company's decision is unfair, you have the right to appeal it. The National Association of Insurance Commissioners recommends these strategies:
1. File an appeal with your insurance company. The reason for denial should be stated on the letter you receive from your insurance company. If you disagree with the decision, file an appeal in accordance with the company's procedure. This appeal should be in writing and may require information from your doctor. If you need more information on your company's procedure, check with your state's insurance regulatory agency usually listed in the state government section of your telephone directory under “Insurance” or “Regulatory Agencies” or through the National Association of Insurance Commissioners (NAIC) directory of state insurance departments at www.naic.org . Click on “Consumer Information Source.”
2. If your appeal is unsuccessful, contact your state insurance commission. Include all the required information, including an explanation of the problem, the type of insurance, company name, your policy number and the name of the agent or adjuster involved. Supply any documentation you have to support your case, even phone notes. Keep a copy of your complaint.
3. Consider other agencies if appropriate. Not all health insurance plans fall under the jurisdiction of state government.
If the health plan is self-funded — your private sector employer or union pays the medical claims — contact the U.S. Department of Labor Pension and Welfare Benefits Administration. The Department of Labor does not interpret provisions of any particular health benefit plan or require employers to pay claims, but may investigate your complaint.
If your plan is offered through a government or church employer, follow the appeals procedures outlined in your benefits booklet and other plan documents. In most cases ultimate responsibility for resolving disputes rests with the governing body of the employer sponsoring the plan, such as a school board.
If you have a disability, you may be protected under the Americans with Disabilities Act (ADA) if your self-funded coverage is dropped or limited. You can reach the ADA Technical Assistance Center at (800) 949-4232 or the U.S. Department of Justice at (800) 514-0301 or (800) 514-0383 (TDD).