Making Them Pay: How to Get the Most from Health Insurance and Managed Care - Softcover

Orin, Rhonda D.

Softcover

ISBN 10: 0312267606 ISBN 13: 9780312267605

Verlag: Griffin, 2001

Inhaltsangabe

A complete guide to modern health insurance and managed care presents an eight-step program designed to help readers get the most for their money, offering tips on analyzing available benefits and coverage, keeping records, uncovering each state's mandatory benefit laws, and getting wrongful denials of care reversed. Original. 20,000 first printing.

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Über die Autorin bzw. den Autor

Rhonda D. Orin is a lawyer with more than a decade of experience suing insurance companies on behalf of policyholders. She has presented cases in courts around the country, and two of her cases have been decided by the U.S. Supreme Court. She works in Washington, D.C.

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Making Them Pay: How to Get the Most from Health Insurance and Managed Care

THE NUTS AND BOLTS

STEP ONE

LOOK OVER YOUR HEALTH PLAN AND FIND THE KEY PIECES

It's time to get down to business--and that means learning the nuts and bolts of health plans. I hate to say it, but you just can't avoid this part. Whether you are trying to pick a health plan or to figure out if something is covered under the one you've got, you need to know how to read a plan.

This chapter is about learning an approach--nothing more than that. The approach is one you should follow with any health plan (and, to a certain extent, with any contract at all). You should follow this approach to figure out if you're covered for anything--from open heart surgery to childhood immunizations. This is basically the same approach that a Supreme Court justice would follow, or a claims examiner at your insurance company for that matter. As far as I can tell, it's the only way to do it.

The first step is simply to find all of the important sections. Don't try to study them in any detail, or spend any time figuringout what they mean. At this point, just finding them is enough; you'll do the rest in Steps Two and Three.

Believe me, finding the key sections is not as easy as it seems. While all health plans contain the same basic sections--like benefits, exclusions, definitions, and so on--each plan seems to put these sections in a slightly different order and to use different titles and terms. Learning how to find them all is more than enough for Step One.

To figure out the structure of your plan, it's best to work with an example. Let's say you have allergies, and you want to know if they're covered under your health plan. Let's say that your health plan is the composite one that's set forth in Appendix A.

By the way, I created this composite, rather than using an actual plan as an example, because I wanted to show that this approach works for all plans, not just for a particular one. This composite is an HMO plan with a Point-of-Service option, meaning the right to see doctors outside the plan, and to submit the bills for reimbursement the old-fashioned way. Its text, and its basic format, is drawn from a number of actual plans.

This composite may seem much more detailed than the materials you've been given about your own plan. Sometimes people have nothing more in their files than one- or two-page summaries of their benefits, usually in a column format. If that's all you have, you're entitled to much more information--and you definitely will need it in order to understand your coverage. Accordingly, it would be a good idea for you to contact your employer or your insurance company and ask for a copy of the entire contract and/or a short version known as the Summary Plan Description or SPD.

By now you know that your first step is just to locate all the important sections, starting with the Benefits. You also know that you're learning an approach--you're certainly not learning whether or not a particular condition actually is covered under a particular health plan.

In fact, if you want to do a quick test of your insurance knowledge, turn to the composite plan in Appendix A right now and see if you can identify all of the sections that relate to allergies. Then, return to this chapter and see if there were any that you missed.

For everyone else, let's get started.

1. THE BENEFITS

It's pretty easy to find the Benefits section in your health plan. It starts at the end of the plan's seventh page. (Remember what I said in the Introduction about not starting on page I?) In fact, you'll find five entirely different Benefits sections. They are labeled as (1) Medical and Surgical Benefits; (2) Hospital/Extended Care Benefits; (3) Emergency Benefits; (4) Mental Conditions/Substance Abuse Benefits; and (5) Prescription Drug Benefits.

Before we're done, I'll end up suggesting that you skim through all five of these sections. For starters, though, you should focus on the Medical and Surgical Benefits subsection. When you turn to it, you'll find a page that looks like this:

1. MEDICAL AND SURGICAL BENEFITS

A. What Is Covered

A comprehensive range of preventive, diagnostic, and treatment services is provided by Plan doctors and other Plan providers. This includes all necessary office visits; you pay a $5 office visit co-pay, but no additional co-pay for laboratory tests, X rays, and prenatal office visits. You pay nothing for well-child care for children under five years of age. Within the service area, house calls will be provided if in the judgment of the Plan doctor such care is necessary and appropriate; you pay nothing for a doctor's house call, or home visits by nurses and health aides.

 

The following services are included and are subject to the office visit co-pay unless stated otherwise.

• Preventive care, including well-baby care and periodic check-ups (co-pay waived for well-child care for children under age five)

• Voluntary sterilization and family planning services

• Diagnosis and treatment of diseases of the eye

• Allergy testing and treatment, including testing and treatment materials (such as allergy serum). You pay nothing. [Emphasis added.]

• The insertion of internal prosthetic devices, such as pacemakers and artificial joints

• Cornea, heart, heart-lung, kidney, liver, lung (single and double), pancreas and pancreas-kidney transplants; allogeneic (donor) bone marrow transplants; autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute lymphocytic or nonlymphocytic leukemia, advanced Hodgkin's lymphoma, advanced non-Hodgkin's lymphoma, advanced neuroblastoma, breast cancer, multiple myeloma, epithelial ovarian cancer, and testicular, mediastinal, retroperitoneal, and ovarian germ cell tumors. Transplants are covered when approved by the Plan Medical Director. Related medical and hospital expenses of the donor are covered when the recipient is covered by this Plan.

• Women who undergo mastectomies may, at their option, have this procedure performed on an inpatient basis and remain in the hospital up to forty-eight hours after the procedure.

• Dialysis; you pay nothing

• Chemotherapy and radiation therapy; you pay nothing

• Inhalation therapy

• Surgical treatment of morbid obesity

• Orthopedic devices, such as braces; foot orthotics, including replacement or adjustment limited to that necessitated by the member's physical changes or growth

 

 

 

 

 

 

 

 

 

 

 

The section continues, and you should skim the whole thing, but you've already found what you were looking for inthe highlighted section: "Allergy testing and treatment, including testing and treatment materials (such as allergy serum). You pay nothing."

In isolation, it sounds great, but nothing in an insurance policy is in isolation. So turn back to the introduction to this list of benefits and read it again--very slowly and very carefully.

Sure enough, you bump right into a hidden qualification. Before you continue reading, see if you can find it for yourself. Here are the key sentences:

 

 

A. What Is Covered

 

A comprehensive range of preventive,...

Details zur Ausgabe

• Verlag: Griffin
• Erscheinungsdatum: 2001
• Sprache: Englisch
• ISBN 10: 0312267606
• ISBN 13: 9780312267605
• Einband: Taschenbuch
• Anzahl der Seiten: 248
• Kontakt zum Hersteller: Nicht verfügbar
• Verantwortliche Person: KreGa Onlinehandel GmbH; 4950000000000; info@krega-onlinehandel.de; ; Birkenweg 31; Brakel; 33034; Deutschland