Tips and Tricks for Dealing with a Recalcitrant HMO

by Sarah Winfrey on 25 September 2009 13 comments
Photo: PhotoDu.de

There is a healthcare crisis in this country. Whether you like Obama's proposed resolution to these difficulties or not, the crisis is very real. And HMOs can be the most difficult of the current types of healthcare to deal with. You don't have to search news stories very long to hear about people who were denied essential treatment when their lives were on the line, or had treatment postponed so long because of bureaucratic red tape that their conditioned worsened beyond medical intervention.

While many of us won't face these kinds of struggles with our health insurance, most of us will, at one time or another, have to struggle with our insurance company over payment approval, referral approval, or any one of a myriad of other common issues. Here are some tips to help get insurance issues resolved as quickly as possible with a minimal hassle.

Talk to a Person

Many times, the number on the back of your HMO card or the one that's available online will take you to an automated system where it's difficult or impossible to get an actual person on the line. Websites like gethuman will help you figure out how to navigate this system so you can talk to a real, live human being. If your problem is at all unusual or difficult, talking to a person and not a machine is essential, as messages are much easier to lose or ignore than a person with a voice and a story whose questions the employee actually has to answer. If you do choose to leave a message the first time, do not assume that the issue is dealt with. Call back and get a person if you don't hear anything within a couple of days, letting them know that you're following up on your message.

Keep Records

Every time you talk to your HMO, or someone at your doctor's office about your HMO, record the date, day, and time you made your call, whether you got ahold of someone or had to leave a message, the name of the person you spoke to, any different departments they transferred you to, and anything relevant that the people you spoke with said about your problem. This may seem like a chore, but these records can help you in a myriad of ways. You may realize that you're speaking to a person that you've spoken to before, and your notes will tell you whether or not they were helpful last time and whether they followed through with anything they might have said they'd do for you. Records also allow you to say, "Yes, I called on [date] at [time] and [date] at [time], etc.," which will often let the person you're speaking to know that this is an ongoing problem.

These records will also serve you well if you ever have to file an official complaint against the insurance company or contest something they say. If you have records of having called to deal with this issue on certain dates and at certain times, they can often check call records or even recordings to find your calls. If you have records of who you spoke to and what they said they would do for you, the insurance company can further investigate the situation with specific employees.

While keeping records won't guarantee that your claims and complaints are handled well, they will help you get the information and give you the leverage that you sometimes need to get things done.

Be Polite

Health insurance companies, like other corporations, are beginning to make notes in files about how cooperative and polite different customers are on the phone. If you're known for having good manners, you're more likely to get the help you need, get passed on to a supervisor if you request it, and deal with people who are willing to go out of their way to help you. It's definitely worth it to develop a good reputation with these companies.

Ask for a Supervisor

If the person who answers the phone can't help you, or if you've spoken to someone at a particular level several times and your issue hasn't been resolved, ask to speak to a supervisor. Sometimes, they will put you through directly. Often, a supervisor has the authority to do things that the ground-level employees cannot do, or they know details of procedures that those employees won't know.

Other times, it will be company policy not to send you directly to a supervisor. In these cases, however, the employee you're speaking to will usually be required to forward your request to their supervisor even if you don't get to talk to them. Ask for this and let them do it if they offer, get specifics on when you should hear back from the supervisor's office, and get the supervisor's name. If you have to call back again, you can ask for the supervisor by name, which is often enough for them to let you speak to the person. You can also say, "{Supervisor's Name} was working on an issue for me and I'm following up on it." Unless you're dealing with a particularly difficult triage system, this is usually enough to get you through to someone who will be more helpful than the person who answered the phone.

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Ask When to Call Back

End every conversation by asking when you can plan to see some resolution to your issue, or when you can call back to expect an update. You can even ask if the person you're dealing with has a direct number so you don't have to go through the receptionist every time. If you don't see any resolution by the date they gave you, or when it's time to get an update, call back and try to speak to the same person you were speaking with before. Remind them who you are, what the issue was, and what they told you about resolution or calling back. This will streamline your process, and will also let the employee know that you're serious about dealing with the issue and are not just going to let it go.

Call Back Frequently

If the employee you're speaking with refuses to give you a date of resolution or a date to check back, call back anyway. Most companies take about 2 weeks to process any changes, so give them about that much time before you call back. If you do this for a period of time and still nothing is resolved, call back more frequently. Every week, every other day, and even every day are viable options. Sometimes, you just have to keep nagging the insurance company before they'll act on an issue, particularly when acting will cost them money. But the squeaky wheel does get the grease, and if you annoy them enough (politely, of course!), then you're more likely to get some response.

Don't use this tactic too early, though. If you make a nuisance of yourself before you've truly given them the benefit of the doubt and not seen a satisfactory response, you'll be labeled a nag and the employees will be less likely to help you. Taking this route involves walking a fine line. Pay attention to the employees' attitudes and the way they speak to you. If they're trying to do their jobs and you're simply not giving them enough time, back off for a week or so.

This is also a good technique to use when a particular employee, especially a lower-level one, refuses to give you what you need or pass you on to a supervisor. Call back later that day, after normal business hours, on the weekend, or the next day and, chances are, you'll get a different employee, who may very well be more helpful to you.

Use Names When You Call Back

If you're keeping records, the first time you call should be the only time when you cannot ask for an employee by name. Having a specific person to ask for immediately marks you as someone who cares about your problem, is more likely to be tenacious in getting resolution, and has enough presence of mind to be keeping track of your conversations. All of these characteristics will make you stand out from the crowd, which will make it more likely that you see some resolution.

Having a name also helps you develop a relationship with a particular employee or group of employees. Sometimes, resolution can be a product of one employee who knows your problem, some of your story, and begins to care for you beyond the normal customer, enough to go our of their way to see that you get what you're looking for. Asking for an employee by name and discussing your problem with them repeatedly can help develop this kind of relationship.

Resolution

In the end, health insurance companies are all about money. If you want them to spend more money on you than they think they should, you will be facing an uphill battle. While the above ideas don't guarantee a resolution to your problem that you like, they do give you a better chance of finding a happy ending to your problem. I'd love to hear any other tips and tricks you've used when dealing with your HMO, so leave them in the comments!

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Guest's picture

As important it is to call them & keep records of that - it is also good to WRITE LETTERS and have a paper trail. You can then also copy people you think might be helpful - like your state's rep for dealing with HMO's - and ALSO send copies of any paperwork you have received - perhaps from an outside provider. I had an instance years ago of an emergency procedure that was covered by my HMO - but for some reason I kept getting bills from the out-of-state hospital. I keep the said hospital on ice for more than 6 months while assuring them via copies of correspondence with my HMO that I was dealing with it - (They wanted ME to pay out of pocket rather than the HMO and I didn't have the $.)It finally turned out that the out-of-town physician hadn't filed the right paperwork for reimbursement by my HMO & it finally did get paid (without me having to put forth a penny of my own.)I also managed to get coverage I had been denied by a gatekeeper, by writing a scathing letter to the head of that department! Squeaky wheels get greased, especially when dealing with HMOs!

Guest's picture
Marvin

I called a Major health provider, (It starts with blue), and asked for a name. I had two names. Each time they said, there was no one there with that name! What's person to do!

.........Marv

Guest's picture
Guest

When you ask for the person's name, ask them if they are located in the US or an offshore call center. If in US, ask for city/state, if they refuse, at least ask for time zone. Also helps to ask for their employee number and their direct telephone #. Not always effective, but has worked for me many times. Distinguishes you from other callers and implies you know their system. They are anxious to keep up their productivity quota and don't like to be slowed down, so most are anxious to take care of your need and get on to the next person.

Guest's picture

You need to do everything you mention here, and remember that persistence is the main ingredient.

Guest's picture
Bobby

Of course the roadblocks are intentional. It's easy to pay your insurance premiums; it's much, much harder to make a claim. The bureaucratic kudzu of making an actual claim is intended to defeat you.

Guest's picture

If you've got a professional you're working with anyway sometimes having that office call gets further. I used to call health insurance companies occasionally for my clients and it seemed to help. At least I could usually get clarification of the issue so the problem could get resolved faster.

Guest's picture
Olivia

Persistance does pay. I remember a particularly convoluted run around on behalf of my elderly mother. It took six months to resolve a medication billing error. I did all you suggested and wrote five letters (the last one, quite funny actually, to the recalcitrant computer, refering to him as "Hal".) I finally found a sympatheic young fellow in the billing department who advocated for Mom within the company by writing internal memos to the computer people. What do ill elderly people do, if they have no one to advocate for them? My mom would have been in a horrible bind if she had to do it on her own.

Guest's picture

Thanks, your website is very helpful

Guest's picture
Guest

As someone who has experienced several HMO denials, fought back and won, I have to disagree strongly with your main advice: calling and writing down a name. The thing that has worked for me time and time again (after a frustrating call) is TO WRITE. Find the address of the dispute resolution dept for your HMO ( either online or in your HMO handbook) and send your complaint in writing via certified mail. Oftentimes there is also a claim form to fill out.

In your complaint letter, document your request as logically as possible and cite your HMO handbook if possible. If you are not a good writer, find someone to review your letter. How you phrase things and how well you back up your claim is crucial. Unfortunately not everyone has a writing background or know legalese that well.

Lastly, I must say that it is unfortunate that in the U.S., you have to fight for your medical rights. In all my cases, the HMO agreed that my tests/procedures were indeed covered. If I had not the time, education level or inclination to fight back, I would have had to pay thousands of dollars despite being one of the 'lucky' insured ones.

Guest's picture
T'Pol

In the early 90's I worked in the US for a few years. In order to match the benefits we had at home, the company I worked for arranged some HMO coverage for me and my colleagues. Due to urinary tract infection, I went to the specified clinic and a doctor prescribed some antibiotic and sent me home. As soon as I finished the medicine, my problem came back. Went back to the clinic, another antibiotic and the same thing happens again. I was real upset and did not know how to deal with it. An American colleague told me to call the HMO Customer Service and tell them that I would sue them if they did not let me see a specialist. Did that and problem was solved. I was very young then and did not quiet know how to seek my rights. See me now!:)

Guest's picture
Guest

Great article on getting things resolved. However, after doing everything you said, you didn't include the last step if you continue to get the runaround (and with some insurance companies you will) ... send a certified letter threatening legal action for wrongful denial of claims.

Consumer protection laws have a "minimum level" federal component and then a state component which often gives you additional protections. There are generally two types of "wrongful denial" actions, one under "unfair and deceptive business practices" and a second for "wrongful denial of insurance claim." To get action for a claim that should be covered but isn't, you should threaten both.

Go to your state attorney generals website and see if they tell you what procedure you need to file a consumer complaint. Here in Massachusetts, you have to send something certified mail called a "M.G.L. ch. 93A Demand Letter" to the person authorized to receive process (you can find this person listed on your state Secretary of State business listing website) threatening that if they don't resolve this issue within 30 days, you are going to file suit in X court (if the claim is for less than $1500 you can file in small claims court for a nominal fee). Type out an outline of the route of the dispute and all action you have taken to date (including those important names, dates, and minutes of conversations). Inform them you will be seeking triple damages for all costs, including court costs and attorney fees. Also, since this is an insurance matter, threaten you will also seek damages under M.G.L. 176D. You'd be amazed at how quickly most issues get resolved once you send the damand letter.

Your exact procedure will vary, but most attorney general offices and/or consumer protection agencies will tell you the proper procedure to follow in your state. Many courthouses have law libraries in them where you can read and photocopy attorney guidebooks (often called CLE manuals) about how to initiate the process in your state.

If they don't resolve the issue within 30 days, go ahead and file a lawsuit. The CLE manual should tell you how. Sit in the back of a courtroom a few hours so you don't get butterflies. Usually then, except unless you're clearly wrong about the procedure being covered, the insurance company will resolve the claim because it will cost them more to hire an attorney to go to court than to just cover the claim.

You can do this yourself if it's for a nominal amount of money ... you only have to pay a filing fee (generally $25 to $180) and fee to have a constable serve the paperwork. For a big, life-threatening issue or issues involving more than $2000, however, you should hire an attorney.

Guest's picture
Suzette

Even better than fighting your insurance company is knowing upfront what your benefits are, so you can avoid conflict in the first place. At the very least, read the summary of benefits; know your copay amounts, yearly deductibles, and maximum out-of-pocket amounts; see health care providers that are members of the network(s) your insurer uses--if in doubt, ask first. Same with pharmacies and coverage for prescription drugs. There are often sound medical reasons for refusing to cover a drug or procedure; it's a mistake to automatically assume that's it's simply because the insurer is cheap.

And yes, I work for a healthcare organization.

Guest's picture
Lucille

A couple of things. It is almost impossible to know your benefits since the benefit books are purposely vague and there are 101 loopholes. This is how many people end up holding the bag for huge medical bills even though they were insured.

Many states do not have a recourse system like Mass. does. But at some point putting all communication in writing rather than over the phone is a really good idea. Insurance companies and obstinate providers hate when people do things in writing. They don't want that paper trail. They want to be able to tell you anything without any recourse by talking to you on the phone. Sometimes simple issues can be resolved with one phone call. When your not getting it resolved quickly start doing everything in writing. If that first letter doesn't get results start sending subsequent letters certified and make sure you keep a copy of those letters and the proof it was received. You absolutely will need it if you ever end up in court over it.

Companies are given the benefit of the doubt in court regarding statements made over the phone or claims that they sent a letter out. The court assumes they are not lying. I can tell you that companies have zero problem making things up in court. If you have a decent paper trail you stand a better chance of overcoming whatever said company is trying to pull.

Insurers or providers have also been known to make claims that people were mis-behaving in the hopes of gaining some sympathy or discredit you in court. I had a provider lawyer try to claim I made a scene in their office when it was clear he was losing his case. I didn't make any scene and he lost the case. But the false accusation really annoyed me. They lose the ability to make things up about you, false statements or misbehavior if it is all in writing.