When You're Dealing With A Bad Health Plan

Managed care companies are often the butt of jokes. They rank up there with lawyers and politicians as an industry that doesn't get universal respect. Still, most health insurance firms who we've dealt with over the years do a relatively good job of servicing their patient base, and some are very focused on improving their industry's ability to provide coverage to more people.

What happens if you find yourself dealing with a less-than-honest insurance or managed care firm? There is a gradual process of escalation for anyone who is unhappy with how their health plan is dealing with them.

What constitutes a health plan not playing fair? Several things, ranging from them inappropriately denying claims, to slow-paying your provider, to not honoring other terms of their contract. It might be inherent that through this entire process, you've filed an appeal and are trying to get any denials overturned, but these steps will be good to help you move the insurance carrier to action.

If you find yourself in the situation of dealing with a poor health plan, here are the steps you should take:

1. Talk to them.
By the time you've determine that your health plan is not being honest with you, you have probably done this step multiple times. However, it is worth mentioning since people may jump to conclusions based on a confusing Explanation of Benefits (EOB) or heresay from their doctor's office. Call the number on your insurance card, speak to a real person, and explain your situation. If you don't think you got a fair answer, move to #2.

2. Have your provider talk to them.
As we've mentioned under several topics, your healthcare provider has a vested interest in getting your claim process. If you aren't getting treated fairly, the chances are they aren't either. Your doctor's office or hospital billing office is often an ally in your effort to get a claim process correctly by your insurance, plus they have the advantage of easy access to medical records and nurses to help argue your case.

3. Involve your employer.
Your employer is the actual buyer of the health insurance. Depending on how large they are, they may be buying 30 to 100,000 policies through the company. That means they have leverage that you don't. Contacting your Benefits or Human Resources department will have a double-benefit: They may point out details of your plan that you didn't understand, and they will also be advocates for you. A timely call by your employer to the insurer can go a long way.

4. File a complaint.
Each state has an Insurance Commissioner or something that closely resembles it, and one of their roles is to advocate for insured patients who are being treated unfairly by their insurance company. In California, for example, the Insurance Commissioner stands ready to act in your behalf if a complaint is filed. They will help advocate in cases of improper denial, slow payment, or other processing issues. It may not be a fast process -- it could take months -- but as a last resort it may be your only technique.