Posted by Bob Johnson (209.211.41.144) on January 18, 2000 at 13:44:25:
This long article is from www.aash.org--American Association for Study of Headache. There are several sections worth exploring under "headache resources".
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Getting Good Care from Managed Care
As businesses cut back on employee benefits, managed care increasingly is the way healthcare is delivered. For those who do not have health insurance through their employer, membership in an HMO or managed care organization (MCO) usually offers the only affordable access to routine and emergency healthcare.
Managed care organizations work to control the costs of healthcare by reducing the number of unnecessary medications, procedures, and consultations with specialists. Those cost controls can be health promoting in themselves by protecting patients from possible side effects and complications of avoidable treatments. Many MCOs also focus on providing excellent preventive care-prenatal care for expectant mothers, well-baby examinations, vaccinations, disease screening, and education in better self-care.
But, MCOs' cost-cutting measures can work against the best interests of patients with chronic but benign conditions such as headache. Headache sufferers who do not get adequate relief from standard medications too often find that their MCO is reluctant to authorize referrals to headache specialists or refuses to pay for more expensive headache medications.
If you are in a managed care organization now or thinking of joining one, you need to be sure you will get the care you need for your headaches-now and in the future if the severity of your headaches changes.
To support headache sufferers in getting access to care, the American Council for Headache Education (ACHE) has created this managed care "survival kit." Here are essential tools and information you need to get the best care from managed care:
"Managed Care or Managed Cost: Treating Patients with Migraine," a 24-minute video in which headache patients and physicians comment on their experiences with managed care.
"Perspectives on Managed Care" from the Spring 1998 issue of Headache, giving commentary and advice on getting good headache care through MCOs.
Tips on choosing a managed care plan and a step-by-step guide to appealing denials.
Template letters for writing to the MCO's medical director, the state insurance commissioner, and elected officials to appeal denials.
A diskette containing the template letters, plus addresses for elected officials, in Mac and PC formats.
Most people wouldn't sign a lease or buy a car without questions and research. Healthcare decisions that impact your health and your quality of life are at least as important. As with any other service or product, you will get more from managed care if you are an active and educated consumer. It is worth the time and effort to understand your options, and to appeal decisions that affect your health and well-being.
What to Ask Before Joining a Managed Care Plan
If your employer offers you a choice of healthcare plans, a little bit of research at enrollment time may save you aggravation and out-of-pocket expenses if you should need to see a specialist or change to a more expensive medication.
Is it a closed network plan, or a point-of-service or preferred provider plan? If it is a closed network plan, your choice of specialists is restricted to the network; with the other plans, you can access specialists outside the network for a higher co-payment.
Can I choose my primary care physician or is one assigned to me?
Can I choose to see a specialist or must all referrals to specialists be authorized by my primary care physician?
Does the plan cover home injection of medications?
Does the plan cover non-drug therapies such as biofeedback or acupuncture?
What is the appeals process if referral or reimburse- ment is denied to me?
How are the physicians in the plan paid-on a fee-for-service basis or by capitation?
Under capitation, physicians are paid a fixed amount per patient regardless of how much care that individual needs. This creates an incentive to limit the amount of care provided. Headache patients often need longer and more frequent consultations to establish a successful treatment plan.
Denials-Don't Take "No" for an Answer
If you are denied a needed referral to a specialist or reimbursement for medication or other medical care, there is much you can do to try to reverse that decision.
Step One. Be sure you follow all the steps in the appeals procedure used by your managed care organization (MCO). Save copies of all forms and all correspondence and keep a log for tracking the dates of correspondence, following up if you don't get a reply. Log any phone conversations you have with the MCO's staff. Keep careful records of the names, job titles, and phone numbers of all your contacts as you make your appeals.
Step Two. Speak to your company's benefits repre-sentative, if your coverage is through your employer and the business is large enough to have a person in charge of benefits.
Step Three. Ask your doctor to write a letter in your behalf, addressed to the medical director of the managed care organization (MCO).
Step Four. Write to the medical director yourself. Template or model letters are included in this kit.
Step Five. If there is no response, send a second certified letter enclosing the first one and asking for an appeal hearing.
Step Six. Contact the insurance executive of your state, your state representative and senator, and U.S. senator and representative. Template letters are included in this kit. Send copies of these letters to the medical director of the MCO.
Step Seven. Consider whether you wish to consult an attorney; if yes, send another certified letter announcing your intention to retain an attorney. If the response is still unsatisfactory, have your attorney write or call the MCO to state your case and your determination to seek legal remedies.
Step Eight. Publicize your case. Send a letter detailing the repeated denials to the local newspaper. Send letters to local and national patient support and advocacy organizations (including ACHE). Again, send copies of these letters to the medical director of the MCO.
Put It in Writing - to Everyone
If your managed care organization (MCO) is denying you needed care for your headaches, you can do something about it. You may feel that it's useless to struggle against managed care rules and bureaucracy, but you do have three important tools at your disposal: persistence, political pressure, and publicity. Don't hesitate to use them. All they will cost you is stationery, stamps and a few hours of your time.
Here are basic letters that you can use as models or
templates in writing letters to appeal your managed care company's denial of care. If you have access to a computer running Mac or Windows software, you can use the enclosed diskette, which contains Word and WordPerfect files of these template letters, plus files giving addresses and contact information for federal and state policymakers.
Letter A. This letter goes to the medical director of your managed care company. (Ask your company's benefit manager or call the MCO to get the medical director's name and address.) Use this letter to appeal a denial of referral to a headache specialist outside the company's network of healthcare providers.
Letter B. If an appeal to the medical director is unsuccessful, you may send this letter to your state insurance commissioner and/or your state representative and senator, and your US representative and senator, detailing the denial of referral you experienced. Be sure to send copies of these letters to the medical director of your managed care company.
Names and addresses for members of the US Senate and House and the state insurance commissioners are provided on the enclosed computer diskette. To obtain names and addresses of other elected officials, look in your telephone directory for the local number of the League of Women Voters and ask for the name and address of your representatives. If you have Internet access, you can find up-to-date contact information on the "Vote Smart" website - http://www.vote-smart.org.
Letter C. If your managed care company has refused to pay for medication or other headache treatments that your doctor considers necessary, use this letter for appealing the denial of reimbursement to the medical director of your managed care organization.
Letter D. If your appeal to the medical director is unsuccessful, you may then send this letter to your state insurance commissioner and/or your state representative and senator, and your US representative and senator, detailing the denial of reimbursement you experienced. Be sure to send copies of these letters to the medical director of your managed care organization.
Names and addresses for members of the US Senate and the state insurance commissioners are provided on the enclosed computer diskette. To obtain names and addresses of other elected officials, look in your telephone directory for the local number of the League of Women Voters and ask for the name and address of your representatives. If you have Internet access, you can find up-to-date contact information on the "Vote Smart" website - http://www.vote-smart.org.
Letter E. If your medical plan is provided by your employer, you may wish to notify your benefits manager of the problems you've encountered with the healthcare plan and enlist his/her help in appealing the denial as a first step. If you are in a smaller company that does not have a benefits manager, you can consider whether you should also inform your human resources/personnel director or employer of the denials. This is an individual decision based on your standing in the company and your sense of your employer's readiness to help with such an issue.
Letter F (denial of reimbursement) and Letter G (denial of referral). If your current doctor is supportive of your efforts to appeal the MCO's decision, you may ask him or her to write a letter to support your case, or to sign one that you have prepared. The two sample letters give some general points that might be covered, but the letter should also include details from your medical history. You can draft the letter yourself if you have a good enough understanding of the issues, or you can offer a copy of the appropriate sample letter to your doctor when you ask him or her to write to the Medical Director of the MCO in your behalf.
Bear in mind that your doctor may feel uncomfortable with your request and say no. In some areas, a single HMO or MCO may control a large portion of the doctor's practice. He or she may be legitimately worried about being decertified-dropped from the company's list of approved providers. Or your doctor may just feel too pressured for time to fight every denial. If so, don't press the point, but continue with your own letter-writing campaign.