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Working with Your Health Insurer: 10 Tips for Families with Children & Youth with Special Health Care Needs
1) Read the materials you receive from your health plan or employer. These may include your service benefit plan, a directory of network providers and other supplementary information. Many private health insurers send periodic newsletters and health promotion materials. These may help you better understand your health benefits and maximize the services your family is entitled to receive.
2) Know your health plans mission, vision and/or core values statements. These statements generally include phrases about providing members with affordable, accessible care, forming working partnerships, and ensuring a members peace of mind. These statements can work to your advantage when you are advocating for a service and/or having problems getting a service covered. Frame your argument using the words your insurer has provided.
3) If your child has special health needs and requires more services than most c h i l d r e n r e q u i r e , a s k y o u r i n s u r e r f o r a c a s e m a n a g e r o r c a r e c o o r d i n a t o r . T h i s i s a f r e e s e r v i c e a n d c a n p r o v i d e a s i n g l e g o t o p e r s o n w h o c a n h e l p y o u u n d e r s t a n d y o u r b e n e f i t s a n d m a k e t h e r e f e r r a l o r p r e a p p r o v a l p r o c e s s e a s i e r a n d f a s t e r .
4 ) R e v i e w e v e r y E O B s ( E x p l a n a t i o n o f B e n e f i t s ) y o u r e c e i v e f r o m y o u r h e a l t h i n s u r e r . C h e c k f o r a c c u r a c y , t h e a m o u n t s p a i d a n d a n y c o p a y m e n t s y o u m u s t p a y . T h i s i s a g o o d w a y t o a v o i d b i l l i n g i n a c c u r a c i e s . I t i s a l s o a g o o d w a y t o m a k e s u r e y o u a r e n o t p a y i n g f o r services your child did not receive or for services that your policy should cover.
5) When speaking with insurance customer service personnel or case managers, be polite. It is easier to build partnerships and get help when youre cooperative and pleasant; no one wants to help someone who is rude or disrespectful. Even if the person is not able to help you, offer your thanks.
6) Work your way up the ladder: If the customer service person or your case manager cant help you, ask to speak to the person who can, such as a supervisor or head of the department.
7) Keep a written record of calls and copies of all letters to your health insurer. Write down the names and numbers of the people you speak with and a short summary of your discussion. If you have a problem getting a service covered, it is more effective to say, I spoke with Ms. Smith on February 1, 2011, and she approved . Rather than saying, The last time I called I spoke with someone, she told me..
8) Insurance companies look at the bottom line: what is this going to cost? Frame your requests in those terms, and in terms of Medical Necessity. Your health plan will have a definition for Medically Necessity in the service benefit plan. For example, tell your insurer, If you pay for speech and language therapy now, 52 visits a year will cost you $XXX. If you dont provide this service, augmentative communication/assistive technology will cost you $XXX in five years when this therapy is no longer an option for my child. RESOURCE: Read exampl e l e t t e r s o f m e d i c a l n e c e s s i t y a t h t t p : / / w w w . m e d i c a l h o m e p o r t a l . o r g / i s s u e / w r i t i n g l e t t e r s o f m e d i c a l n e c e s s i t y .
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