Kids and Health Care: Using Your Doctor as a Tool

If you understand the relationship that your doctor and your insurance coverage play in the delivery of health care, you can use each to maximize the effectiveness of the other.

Your doctor should be familiar with your insurance coverage, so he or she can provide you with covered care. However, there are so many different insurance plans that few doctors can keep up with the details of all of them. By knowing your insurance coverage, you can encourage -- perhaps even prod -- your doctor to recommend medical care that is covered in your plan.

Remember that your insurance company, not your doctor, makes decisions about what will be paid for and what will not.

Don't hesitate to write, e-mail or call your insurance company with questions about coverage for specific conditions, before going to the doctor. Finding the right person to e-mail can take time. And calling may mean some time spent on hold...but it's better to know what your insurance company will pay for before you receive a service, get tested or fill a prescription. Some kinds of care may have to be approved by your insurance company before your doctor can provide them.

Most of the things your doctor recommends will be covered by your plan, but some may not. And, in many cases, you won't find out coverage was denied until weeks...or months...later, when you get a bill. This is the worst way to find out about a coverage issue, because you've already received the service or therapy. You can try to get the insurer to pay after the fact, but it's better to have an idea of what will happen in advance.

If your insurance company denies your claim, you have the right to appeal (challenge) the decision.

Before you decide to appeal, know your insurance company's appeal process. Also, ask your doctor for his or her opinion. If your doctor thinks it's right to make an appeal, he or she may be able to help you through the process.