Perspective               

Providers Fight Health Plans over Denials for Care and Services

A recent survey of doctors and nurses by the Kaiser Family Foundation finds that providers and health plans frequently disagree on what care is appropriate for patients. Almost nine out of ten doctors said their patients have been denied coverage for health services over the last two years, with denials reported most frequently for prescription drugs. Two-thirds of doctors said they see denials on a weekly or monthly basis for prescription drugs they order. Two-thirds of doctors said they often or sometimes argue with plans on their patients' behalf.

If you are in a Medicare HMO and cannot get the care you need, or if your HMO refuses to pay for your care, remember – you always have the right to appeal your HMO’s decision. When you appeal, there is a good chance you’ll get the care or payment you deserve.

Appealing an HMO denial of care or refusal to pay is free and pretty easy. All it takes is a letter to the HMO asking it to reconsider its decision. It helps if you include a letter from your doctor explaining why you need care, but you do not need your doctor’s help to appeal. There is no reason not to appeal. You have a one in three chance of getting the care you need, and Medicare HMOs cannot disenroll you or deny you future services if you appeal a decision. Medicare HMOs must reply to your appeal in a timely manner and send any appeal decision that is not fully in your favor to an independent review committee.

Medicare rules were recently changed to make HMOs decide more quickly if they will give care or coverage. If you do not receive the care you need and you appeal, your HMO has 30 days to decide if it will reverse its decision or forward your case to the next level of appeal. If you have already received the care and are appealing refusal by your HMO to pay for it, then the HMO has 60 days to decide.

Sometimes, 30 days is too long to wait to find out if an HMO will give you care you desperately need. If your HMO denies urgently needed care, the delay of which could put your health in serious danger, you can get a fast appeal within 72 hours. If your doctor asks for a fast appeal, the HMO must make its decision within 72 hours. If you ask for a fast appeal on your own, your HMO can decide whether it will make its decision in 72 hours.

To get help with your Medicare HMO appeal, call your State Health Insurance and Assistance Program, or SHIP. The number is in the back of the Medicare & You booklet which was sent to people on Medicare. You can also get one by calling 1-800-MEDICARE. Your Senator or Congressperson should also have staff who can help you.

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