Introduction to Health Insurance Problems and Solutions

Introduction

I've been writing a newspaper and magazine column on health insurance issues for a number of years. During that time, I've found that many types of health insurance problems have be come rather commonplace in America. In fact, if you've been covered by a health insurance policy for more than a few years, you've probably encountered at least some of these problems.

You file a claim and never hear from your insurance company again;
You file a claim, and your insurance company responds with a message that's so cryptic that you feel as if you need a translator to even begin to understand it;
Your insurance company sends you a check for far less than you think you're entitled to under the terms of your policy, and you have no idea why;
Your insurance company sends you a check for far more than you think you're entitled to under the terms of your policy, and you have no idea why;
Your insurer sends you a letter asking you to send your claim to your automobile insurance company first, and to include a copy of the accident report when you re-file your claim, but you haven't been involved in an accident and you haven't filed a claim in months;
Your insurance company pays your hospital bill, but then insists that the hospital return the money, and the hospital has now asked you to pay the bill;
You receive a check from your insurance company, but you are certain that you haven't filed a claim;
You've been reimbursed twice by your insurance company for the same claim;
You've had the same insurance policy with the same com pany for years, but your insurer has suddenly begun to re ject your claims on the grounds that you've never been in sured with the company;
Your Medicare carrier has informed you that Medicare is now your secondary insurer, and that your primary insurer is a company you've never heard of;
Your insurer insists that your doctor's bill is far above the usual and customary rate, but your doctor assures you that her fees are the same as, or lower than, other doctors in the area;
Your insurance company has requested additional information before it will continue processing your claim, but no one to whom you've spoken at the insurance company seems to be certain what information is required.

I've found that a large percentage of such problems, includ ing many of those that seem overwhelmingly complex at first, turn out to be the result of either simple claim-processing er rors or difficulties in communication. Once the nature of the problem becomes clear, it's often fairly easy to find a solution.

However, in order to analyze a health insurance problem, you need to have the proper tools. That's true of almost all fields. Whether you're trying to build a new deck on your house, repair your car, or make sense of your taxes, you need to have the right tools in order to do the job properly. This book is designed to help you develop the tools you need to solve your health insurance problems. I hope, as well, that the book will allow for the development of an overall understanding of the current health insurance system in America, so that you can participate more effectively in the current debate on health care and health insurance reform.

This book is intended to meet the needs of a number of specific groups, including

consumers insured through individual health insurance policies, employment-based group health insurance plans, HMOs or other types of managed care plans, self-funded plans, or CHAMPUS;
individuals covered by Medicare, Medigap policies or secondary health insurance policies, or Medicare HMOs;
children and adults with disabilities or special health care needs who are covered by Medicaid or by private health in surance policies;
parents of children with disabilities or special health care needs who are seeking an alternate method of paying for medical expenses;
people trying to help a friend or relative deal with a health insurance problem;
people who are trying to help their parents or grandparents obtain coverage for home health care, nursing home care, or other types of long-term care;
professionals such as doctors, nurses, benefits managers, human resource managers, claims supervisors, and hospi tal billing department supervisors.

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