Safeguard your health services

Take steps to keep managed care insurance plans in line

Seven out of 10 employers now offer managed healthcare plans to their employees, and that number is expected to grow. Under managed care, employers benefit from the reduced rates offered by participating providers while health professionals can depend on a steady flow of patients. Unfortunately, critics have accused managed care plans of cutting costs at the expense of quality healthcare-meaning that it’s up to you to ensure that your interests are well protected.

The Center for Patient Advocacy (www.patientadvocacy.org), a nonprofit organization that has been a proponent of Managed Care Reform since 1995, receives thousands of complaints from concerned patients about the reduction of quality health services. The most common ones are that managed care plans limit patient access to specialists; prevent doctors from recommending customized care or revealing treatment options that aren’t covered; restrict coverage for emergency room care; and cause patients to tackle excessive red tape to obtain special authorizations. As a first step toward quality service, the Center advises that you document everything related to the medical care you received, including the dates and times of the service, names of the providers and any correspondence you’ve written expressing a complaint.

Dr. Donald “Ted” Lewers, vice chair of the American Medical Association’s Board of Trustees, also suggests that you maintain a good relationship with your doctor. “The patient/physician relationship is critical to quality healthcare,” he insists. While some industry studies show no differences between the quality of care patients receive under managed care and fee-for-service plans (except for chronic conditions), the results don’t tell the full truth, Dr. Lewers points out. “Being able to choose your physician is part of offering quality healthcare-especially since 80% of the American public want to select their own physician and say this is the most important component of a health plan.”

Dr. Lewers and the Center suggest that you direct specific questions to insurance carriers-even before you sign up. Can you retain your current physician? Can you change physicians? What portion of the expenses are covered if you go outside of the plan’s network of providers? Do you have the right to an internal and external appeal? How long do you have to wait if you decide to drop out of the plan altogether? By getting answers to these questions, you can make decisions about your healthcare. Here are some additional suggestions:

  • Read the contract thoroughly. Review your health plan’s contract in its entirety. Be sure to note the plan’s deductible and co-pay amounts as well as the services it covers. If you come across things you don’t understand, contact your company’s benefits administrator or the plan’s customer service department.
  • Familiarize yourself with the external appeals process. Under the Patient Protection Act you can take your complaint or concern to a group of impartial individuals, usually health professionals or experts, for an assessment of your case. Since external appeals programs are only offered in some states, contact your local insurance commissioner’s office or the insurance plan for guidelines.
  • Contact your elected officials. Managed care regulations vary by
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