Dealing with Problems in Managed Health Insurance Care Plans
Part 2, Chapter 7: Managed-Care Plans Page 8
Continued from Previous Page
Dealing with Problems in Managed Care
Services and treatments offered through managed care plans are generally handled routinely, with few difficulties. Unfortunately, when participants in managed care plans do experience problems, they may be very difficult to resolve. The problems commonly reported with managed care plans at this point include difficulty in obtaining reimbursement for
- treatment in a hospital emergency room;
- a consultation with a specialist outside of the plan network;
- treatment beyond what the managed care plan may deter mine to be medically necessary;
- hospitalization or services such as physical therapy-which generally require pre-authorization-in cases in which no pre-authorization was granted.
It's often possible to prevent such problems from occurring by carefully following the rules of the managed care plan, and by keeping careful records of all communications with plan representatives that relate to coverage or reimbursement. If a problem occurs in terms of coverage or reimbursement, it's important to make full use of the managed care plan's appeals system. File a claim appeal at each stage of the process until the issue is resolved, and keep copies of the appeals and the responses you receive. If your appeals are unsuccessful, you may wish to consider the possibility of writing to a supervisor or an executive at the managed care plan.
Continued on Next Page
