A Guide to Your Rights

• An Overview and Introduction
• Health Insurance
• Patient Safety
• Private Benefits:
  Motor Vehicle Insurance
• Private Benefits: Disability Insurance
• Private Benefits: Workers Compensation
• Public Benefits:
  Commonwealth Of Pennsylvania
• Public Benefits:
  Crime Victims Compensation Fund
• Public Benefits:
  Federal Government
• Public Benefits: Attendant Care
• Disabled Children
• Rehabilitation Hospitals
  & Facilities
• Vocational Rehabilitation Services
• Civil Litigation: Claims For Damages
• Resources
• Support Groups
• Entitlements And Benefits
• Acknowledgements

 

Health Insurance

Until recent years, the overwhelming majority of Americans received health insurance through their jobs. Those numbers have declined somewhat in recent years, but employer-sponsored health insurance remains the most common source of health insurance.

Whatever the source, health insurance is almost always the primary source of funding for health care and rehabilitation services after a serious injury. Health insurance comes in many, many different forms. A Health Maintenance Organization, or “HMO,” often includes a gatekeeper physician who must approve all specialty referrals and consultations. Another common arrangement, known as a “Preferred Provider Organization,” does not require a gatekeeper to pre-approve specialist referrals, but does impose additional costs (such as a larger co-payment) if the specialist is outside the preferred provider network. Under traditional “indemnity” plans, the health insurer pays 80% of the costs of medical care, and the patient pays 20%.

Whatever the precise configuration of health insurance, one universal feature is the presence of some form of “utilization review”. Insurance companies have review mechanisms that allow them to influence, and in some cases participate in, decisions that affect which health care and rehabilitation services get reimbursed and which ones don’t. All too often, a decision to deny reimbursement is in practical effect a decision to deny the patient the care. Sometimes these insurance decisions are not consistent with the medical recommendations of the doctors and therapists who are working with the patient and who know the patient best. All too often, it falls to family members and loved ones to ensure that the family member receives the medical care and rehabilitation services needed to give the patient the best chance at the maximum recovery possible.

When a health insurer approves or refuses approval for medical care in advance of the medical care being provided, the process of insurer review is called “prospective utilization review”. Prospective utilization review is present to some extent in virtually every form of health insurance available today, even forms of health insurance not typically seen as “managed” care, such as PPO’s and traditional indemnity plans. Health insurer review that occurs after the fact is often called retrospective utilization review. top

Insurance companies sometimes participate indirectly in decisions that affect health care and rehabilitation, through the use of direct and indirect incentives in the insurers’ financial arrangements with healthcare providers. These financial arrangements are set up in an effort to control the costs of health insurance, and most of the time do not have any adverse effect at all on patient care. Sometimes, however, these incentives and financial arrangements can potentially play a role in medical decisionmaking.

In the face of catastrophic injuries – and the enormously expensive medical care that follows a catastrophic injury – it is helpful to bear in mind that patients and their families, and their healthcare providers, are looking out for the patient in ways that no outside insurance company possibly can. Sometimes, providers and families do not see eye to eye with managed care health insurers, regarding what medical care a patient needs and what medical care is and should be covered under the insurance policy. These disagreements can take many different forms: the insurer may question and refuse to pay for care on the ground that it is not covered. They may seek to limit the cost or duration of care, or even question the reasonableness and necessity of medical care recommended by treating clinicians. Whatever form this managed care interference takes, it is important that the family and medical care providers fully understand what the patient’s rights are, under the insurance policy itself and also under the laws of Pennsylvania. Sometimes, it takes a strong stand to ensure that a patient receives the medical care he or she is entitled to.

Before turning to specific tips for dealing with health insurers, it is worth stressing that the most important point, by far, is communication with doctors, nurses, and therapists. Talk to them. Know what they are doing for you or your loved one, and know what they think will help. Find out what they think, what the prospects are, what the treatment options are, and what treatment settings are appropriate and will be appropriate in the future. If you don’t think you know what is going on, ask the healthcare providers for some time. If you are in a hospital or other institutional setting, a social worker will often be able to set up a meeting to discuss treatments and treatment options. A solid and informed relationship with healthcare providers is the single most important step you can take to ensure that you or your loved one get the best care possible. top

In addition, there are some other straightforward things that you can and should do if there is any prospect at all that a dispute might arise with the health insurer.

1. Obtain a copy of the insurance contract that establishes and governs the available benefits (sometimes this is a document that is referred to as a “plan document”). Although often quite dense and difficult to read, these documents create legal rights and obligations for the patient and for the health insurer. Health insurance companies are required by law to provide these documents.

2. Know and understand the nature of the injuries, the treatment being recommended and its alternatives, and the reasons for the recommended treatment. Letters from physicians to the healthcare coverage provider outlining these issues are always helpful in the event of dispute, and may be necessary.

3. Be persistent. If a health insurer disagrees with what a treating doctor, nurse, or therapist says (or what you understand the health insurance policy to require), do not take the first “no” as an answer. When dealing with a claims person or adjuster, do not be afraid to ask to speak to a supervisor.

4. Keep records of your managed care contacts. Record, in one notebook, all communications with the health insurer. You should write down the date and time of all communications, the name and title of the people you speak with, and a brief summary of the conversation. (It is important that you use a single notebook or notepad so that you have all these notes in an easily accessible place.) If you have to leave a message for someone, record that in the notebook too.

5. If a managed care representative tells you that they will get back to you, ask them when they will do so. Ask if there is some way that you can get back in touch with them, in the event that they do not follow up with you as promised.

6. Whenever you write to an insurer, keep a copy of what you send and make a note of when you sent it and how. If you can, it’s a good idea to send things by both first class mail and certified mail, return receipt requested (the first class mail will get there sooner, and certified mail will result in a receipt that confirms delivery in the event the materials get lost).

7. Most healthcare insurers have a variety of internal processes that purport to evaluate the medical necessity of care and determine the care for which they will pay. Pre-certification, peer review and similar processes may result in denial or limitation of coverage, significantly affecting a patient’s medical care. These decisions are not final and are subject to formal and informal challenge. These decisions can be arbitrary, unfair and wrong. Improper conduct in these processes can be the basis for litigation on behalf of the patient.

8. Be aware of the healthcare coverage provider’s claims and appeals procedures. Many insurance policies and employee benefit plans set forth specific processes that must be followed to file and pursue a claim and to appeal any adverse determination. Often, there are strict time deadlines within which action must be taken. For example, it might be necessary to file a complaint or a grievance within a specific number of days after a decision. Ask about these deadlines, and ask the insurer to send you information in writing that tells you what the appeal procedures are and how you can follow them. Failure to know and follow these procedures can result in forfeiting rights the patient might otherwise have. top

The complicated administrative processes established by many managed care providers can be daunting for even the most motivated and focused family members. This is especially true when a family is still dealing with the burdens of a catastrophic injury. Obtaining and utilizing the services of an advocate, whether formal or informal, whether legally trained or otherwise, can sometimes mean the difference between receiving quality care in a timely fashion, and unnecessary delays and denials that can effectively deny a patient the best chance at recovery. Often, case managers in a hospital or rehabilitation facility are extremely effective advocates for patients, doctors, and therapists. In some situations, however, the assistance of an attorney may be necessary.

The Pennsylvania Attorney General has a healthcare unit that can be a helpful resource for patients, their families and their advocates. In certain circumstances, the Attorney General may investigate or take action on behalf of consumers. This unit can be contacted at:

 

Office of the Attorney General

Health Care Unit

14th Floor

Strawberry Square

Harrisburg, PA 17120

(717) 705-6938

http://www.attorneygeneral.gov/ppd/health/index.cfm

 

You should be aware, however, that the Attorney General’s powers in this area are sometimes limited. When you contact the Healthcare Unit, you should discuss at the outset whether or not your particular situation is one where the Attorney General is likely to be able to help.

There are also private companies that assist insureds, and act as their advocates, during the managed care appeal process.

There is a firm headquartered in Philadelphia, Healthcare Advocates, with a national reputation in this area. http://www.healthcareadvocates.com.

There are also attorneys who specialize in managed care issues.

If a catastrophic injury leaves the family breadwinner out of work, families often need private health insurance to continue after an accident. Under a federal law known as the Comprehensive Omnibus Budget Reconciliation Act of 1986 (“COBRA”), eligible employees can continue to purchase their health insurance benefits from their employers for a period of up to 18 months after employment has ended. Normally an individual must affirmatively elect to receive this coverage within 30 days after receiving notice from the employer that they are eligible for this continued coverage. Changing health care plans after an accident can sometimes result in a gap in coverage for pre-existing conditions, and this can make COBRA coverage even more important.