- The Washington Times - Tuesday, June 8, 2004

Q: How can I ensure that my medical treatment isn’t shortchanged by myhealth plan’s financial concerns?

A: When you are diagnosed with a disease, you should immediately start educating yourself about your condition and the treatments that are considered the best for it, said Arthur Levin, director of the Center for Medical Consumers. Such knowledge will help you understand whether you are receiving good care.

Mr. Levin suggests that consumers turn for information to nonprofit groups such as the American Heart Association or the American Cancer Society. The Internet is full of sites about drugs and diseases, but many are designed to promote a product. Be wary, Mr. Levin said.

Nonprofit groups can help you find the best doctors and hospitals in your area to treat your illness, but some of these health care providers might not be in your health insurance network. If you don’t think that your network has the best specialists, talk to your employer about possibly widening the circle. Some states have laws that require plans to have a certain number of specialists within a geographic range and who are taking new patients.

Still, you may have to go outside the network and pay out of pocket to see the best doctors. If so, ask the doctor whether he or she would accept what your plan pays other similar specialists.

Many plans have a finite number of brand name drugs with an affordable copayment. Most plans do reimburse you for other drugs if your doctor says they are medically necessary, so ask your physician to intervene for you if necessary. If your plan doesn’t cover the drugs you need, some pharmaceutical companies provide free drugs in certain circumstances. Again, ask your doctor for help.

If your doctor recommends a treatment he or she deems medically necessary and your plan declines to cover it, you have several options. First, ask your plan to review its decision. If it still refuses to pay for the treatment, 43 states offer an independent, outside review process. You also can sue your health provider to get them to pay for the treatment.

Sometimes the problem is that you have selected an inexpensive, limited plan. Karen Pollitz, project director for Georgetown University’s Health Policy Institute, suggests purchasing a different plan when the new enrollment season begins. She says you won’t be penalized for your pre-existing condition as long as your coverage doesn’t lapse.

Mohit Ghose, spokesman for America’s Health Insurance Plans, said patients should discuss their concerns and problems with a representative from the health plan.


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