The Consumer’s Right To Health Care: How To Overturn Managed Care Treatment Denials
Posted Nov 18 2008 12:17am
The Consumer’s Right To Health Care: How To Overturn Managed Care Treatment Denials: "The cost of health and mental health care is soaring in this country. As a result, governments and insurance companies are increasingly using managed care -- which, in simple terms, is any approach to contain ( = reduce !) healthcare expenses. One of the primary cost-cutting tools of insurance companies that 'manages' care is a process called utilization review. Under utilization review, a person on staff with your insurance company discusses your treatment with your mental health provider. The insurance company’s goal in reviewing your treatment is to determine two things: * If the treatment your provider recommends is covered under your health insurance plan; and * If your condition is "medically necessary," that is, if the insurance company feels that your treatment is essential for your physical and/or mental health. Based on these two factors, the insurance company will "authorize" or "deny" payment for your treatment. It is often surprising to consumers when services are denied. For example, your insurance benefits may indicate that you may make 20 visits to a care provider, and your provider agrees that you need these services, but the insurance company tells you that they will not pay for your treatment anyway -- because it wasn’t medically necessary. In fact, most insurance company denials are based on medical necessity. Fortunately, insurance companies that use utilization review are required to offer an appeals process for treatment denials. If an appeal is made, consumers and their families need to be prepared to advocate aggressively for the care they need. The primary way to do this is by communicating with the insurance company’s consumer or member relations department. This document provides information on what you can do to reverse treatment denials." This teaches how to fight for your rights !