Got a beef with your health insurance plan? Join the crowd: According to a survey by the Kaiser Family Foundation (KFF), almost half of those under age 65 had had a problem of some sort with their plan in the year before they were polled for the 2001 study.
"Navigating the dispute resolution process can be overwhelming,"says Drew Altman, president of KFF, which is independent of the Kaiser Permanente health system. To make that navigation easier, the foundation has issued a new edition of its "Consumer Guide to Handling Disputes With Your Employer or Private Health Plan," available for free at www.kff.org/consumerguide or www.consumersunion.org.
"The health plan may be justified in refusing to provide or pay for treatment," the guide points out. It provides a checklist for understanding a policy: Do I need a referral for a lab test or a visit to a specialist? Are referrals limited to providers within the plan's network? Is there a limit on payments for certain types of care?
The guide notes that a consumer's right to appeal a denial of coverage may not apply if the employer "self-insures." About half the people covered through an employer are in self-insured plans, according to KFF vice president Gary Claxton. Aetna's name may appear on your insurance card, for example, but Aetna may be merely administering your plan, with your employer providing the actual insurance. (Don't know if your plan is self-insured? Ask your firm, try reading your policy or call the U.S. Department of Labor at 866-444-3272.)
A federal rule that went into effect in January expands the appeal rights for everyone covered by private health insurance, including those in self-insured plans, says Claxton. "It's a big step forward," he says, setting standards for how -- and how quickly -- an insurer must respond to a consumer complaint. (People insured through the Federal Employees Health Benefits Program have a separate set of appeal rights, according to a spokesman for the Office of Personnel Management.)
The guide details how each state requires insurers to handle disputes and how consumers can obtain independent reviews of those decisions. In the District, details can be found online at www.dchealth.dc.gov or by calling 202-442-5979; in Maryland, www.mdinsurance.state.md.us or 800-492-6116; in Virginia, www.state.va.us/scc/division/boi or 800-552-7945.
While some disputes involve expensive, experimental therapy that an insurer refuses to provide, denials also include small items. Consider the Maryland Insurance Administration's announcement last week that it had fined CareFirst BlueCross BlueShield $400,000 for a series of violations. Among them: 3,452 claims for rapid strep throat tests that CareFirst had rejected. The insurer has now paid them, at about $15 each.
-- Tom Graham