Insurance Strategies

Subject: Dealing with your Insurance Company

Date: Tue, 14 Oct 1997

From: David Gates <>

Organization: PA Health Law Project

Strategies for Dealing with Health Insurance Companies and HMOs

Guiding principles for dealing with insurance companies:

What to do when you're told the service or equipment isn't covered:

Determine what is covered:

If there's a reasonable argument under the master policy that the service or equipment should be covered, file an appeal (see below)

If not covered under the master policy try to make a deal

It is possible for folks at a hospital or providers office who deal with the insurance companies to sometimes convince the insurance company or HMO to cover something not normally covered where the uncovered service is essential to ensure the effectiveness of another service the insurance company or HMO is going to pay for. Also possible where you can trade some coverage for an otherwise uncovered service

Medical necessity determinations

What's needed in a letter of medical necessity:

Working with the prescriber

Where the plan offers a less expensive alternative

Whether the providers who are in the plan's network or will accept the reimbursement offered by the plan are accessible and competent

Lack of providers with physically accessible offices (For HMOs and PPOs)

Lack of competent specialists

Filing appeals/grievances with HMOs and "gatekeeper" PPOs (Preferred Provider Organizations)

Complaints vs. Grievances

Levels of Grievances

1st Level Grievance

Subscriber rights

Grievance Committee

Grievance decision

Time limits

HMOs should provide between 30 and 60 days from the date the 1st level grievance decision is issued for an subscriber to file a 2nd level grievance.

Grievance Committee

Date/notice of hearing

Right to appear/ be represented

Right to question staff

The subscriber has the right to question HMO/PPO staff at the grievance hearing concerning the dispute.

Disputes involving differing physician opinions

Hearing process

Hearing decision

3rd Level Appeal- Dept. of Health

Time limits

The subscriber has 30 days to file his/her appeal with the Dept. of Health "unless extenuating circumstances are involved."

How to appeal

Appeals to the Dept. of Health are to be made in writing and mailed to: Bureau of Managed Care Room 1026 Health & Welfare Bldg. Dept. of Health PO Box 90 Harrisburg, PA 17108-0090

Departmental hearing

The Dept. of Health may hold its own hearing, require the HMO/PPO to rehear the grievance to address specific issues or decide the case on the documentation supplied by both sides.

Expedited grievances for "medically pressing issues"

Persons on Medical Assistance in HMOs

What to do for more help

drafted by David Gates 10-14-97
Permission granted by David Gates to reprint article with credit attributed to the PA Health Law.

The Noonan Syndrome Support Group, Inc. and any associated parties will not be held responsible for any actions readers take based on their interpretation of published or disseminated material. Please review medical treatment and decisions with your physician.