Posted by Dave (152.163.213.183) on March 07, 2000 at 09:39:00:
In Reply to: Dave you seem to have knowledge on this subject posted by NickD on March 06, 2000 at 23:23:23:
Hi Nick,
It's not so much that I have a lot of knowledge
about HMO's, but more that I hate to be intimidated by them or any of the "big guys".
I will lend money to co-workers and forget about it right there. Never ask about it again. If I get paid back fine, if not, fine. I only bring this up to so you'll understand where I come from.
Money does not impress me, if I had a lot, I'd give it away. But, I will not let a corporation or such take advantage of me. Not because of the money, but because of principle.
I've found dealing with HMO's like playing poker.
And they are good blufflers. That's how they win so often. I've had to "play" with them 4 times in the last 3 years. Each time, I knew I had the cards to win, but since they had the "backers", they could afford to keep raising the stakes. This brings you to the point of wanting to fold because it's "just to much". Well, I simply just
don't fold. They pay up, and don't care because they win so many other bluffs, they're still ahead of the game.
Okay, so what do I do?
First off, I call my doctors office and see where they stand. Next the insurance company, and finally my work place.
The key lies in getting things out of them you don't see on the "disapproved" letter. I like to make sure I ask things like " What is your name and your responsiblity to this matter so I know who I can quote as a representive of your outfit."
Needless to say, this one simple statement turns the tide quickly. Trust me, you'll hear a sudden
hesitation on the other end, as they think about where this could lead. And will then try a little ass kissing...don't be fooled by that. You've already shown them you mean business and are taking control of the conversation. That THEY WORK FOR YOU! You pay for their services and will hold them accountable. As they now guard everything else they say (with a lot of "hems" and "ha's" mixed in) you must stay firm. And, once you have them here, you can talk polite and confident. And I will usually end the conversation with something along the lines of:
"Thank you 'so&so' I will be using the information you gave me in my letter of appeal. I suggest your office take care of this matter immediately upon reciept of my appeal so it doesn't have to go any further."
Then, write the appeal! Add in the info you got from each call. Keep the letter as polite as possible but very firm. Let them know you are prepared to go the distance. (In a couple of cases I even reminded them how much this will cost them). Be careful not to overdo it though, just state your case implying your confidence and firmness.
So far, I've won all cases on just these simple steps. If it goes further, don't back down! (Of course I'm assuming you are in the right). I've fought other big corporations in the same manner, and have not lost yet. They really don't want to pay the cost of a legal battle.
In the case of your daughters dental, I'd take the above route. Also mentioning the fact that treatment started the same day your dentist agree the treatment was needed. The day your "primary care dentist" said the work needed to be done is the date I would stand on as the start date for treatment.
So, basically, like I said, it's not so much a knowledge of HMO's or legal systems. It's more or less just standing up for what is right. And, I must admit, the money saved doesn't mean much, but my respect for myself for not letting them screw me around is the real victory.
Hope this helps a little, I'd be more than happy to help in any other way possible to any of you who also want to stand up and fight. Don't these companies know they're going to battle with CH'ers? A group of strong willed tough people who have stood up to a bigger beast than they'll ever be!
Best of luck : )
Dave