HEALTH RIGHTS HOTLINE Independent Assistance For Health Care Consumers

When it comes to matters of health, it is important to speak up if you are dissatisfied with the quality of care you receive, the services provided, or if you believe you are entitled to more or different benefits than you are receiving. Health plans, government programs such as Medicare and Medi-Cal, and agencies that oversee health plans have formal steps for you to follow if you have a problem or complaint.

Some Reasons People Have Problems

Problems may come up for many different reasons. The most common reasons come from difficulties getting specialty care; limitations on services or benefits; denial of a claim because the services are not considered a covered benefit or the care was received outside the plan's network of providers; dissatisfaction with the quality of care received; or, the length of time it takes to see a doctor or get treatment authorized.

Seeking To Resolve Your Problem

Determine what you want. Decide whether you just want someone to know what happened to you or if you want a change and/or a resolution. Think about what you would consider a fair or positive solution to your problem. Know what you want!

Action Tip efore calling your health plan or another group about your problem, write down what you want and what happened to you. Putting what happened in order by date is helpful. Be sure to keep notes of all contacts you make regarding your problem.

Check your contract. If you believe that you have been denied covered benefits or services, including medical services you need right away, look in your health plan documents, often called an "Evidence of Coverage" (EOC) or "Summary Plan Description" (SPD). You should have received this when you signed up with your health plan. If you can't find your EOC or SPD, ask your employer or your health plan's customer service department to send you one.

Action Tip If you write a complaint, state the specific benefit you want the same way it is written in the EOC.

Talk to your doctor. If you are dissatisfied with services from your doctor or other health professional, speak with him or her directly and see if you can come to a better understanding. Your relationship with your doctor should be a partnership. Speak to your doctor about your concerns, and give him or her the opportunity to fix the problem. You have the right to choose another doctor if you remain dissatisfied.

Contact the medical group. Many doctors are part of a medical group that may have specific rules for doctors to follow. Medical groups may be able to approve or deny referrals to specialists or for certain tests, treatments, or medical equipment. Your doctor also may need special approval to refer you to a specialist outside the medical group. Most medical groups have patient assistance departments that can help you find a doctor, work out billing problems, or obtain referrals and authorizations for services.

Action Tip Ask your doctor which medical group he or she belongs to. You also can ask your health plan's customer service department which medical group your doctor is in. Your doctor or health plan should be able to give you the telephone number for the medical group's patient assistance department.

Call your health plan. Ask your doctor which medical group he or she belongs to. You also can ask your health plan's customer service department which medical group your doctor is in. Your doctor or health plan should be able to give you the telephone number for the medical group's patient assistance department.

Action Tip Be persistent. Follow-up with your medical group or health plan. Ask when you can expect a response. Call the medical group or health plan again if you do not hear back in a reasonable amount of time.

When you call your health plan or medical group, your complaint may be recorded, either by entering your information on a computer or by taping the call as part of the health plan's monitoring of customer service calls. You should be told if a tape recording is being made. This is one way that health plans and medical groups can measure the satisfaction of their members, but it also means that whatever you say could become part of your record.

Action Tip Be sure to describe any efforts you have already made to resolve the problem. Tell the health plan or medical group representative who you have talked to, when you talked to them and what you were told.

Talk to your employer. Talk to your employer. If you get your health coverage through your own or your spouse's job, the human resources or benefits manager may be able to help resolve any questions about benefits and health plan policies. If you received an employee handbook, check to see if there is a procedure to follow regarding questions or problems with your health benefits.

Formal Grievance and Complaint Procedures

If you are not satisfied with the resolution of your problem, you can file a formal grievance. A grievance may be filed with the health plan or medical group, or both, and also with certain government or private agencies. You should submit your description of the problem in writing.

Action Tip When you are mailing an important document, such as your grievance or appeal, it is a good idea to send it Certified Mail with Return Receipt Requested so that you can verify the date your letter was received by your health plan or medical group.

Check your contract. Check your health plan documents (your EOC or SPD) for a description of your health plan's grievance process. You have the right to a timely response, especially if your disagreement is over denied medical services you feel you should receive. The EOC or SPD should tell you how long the health plan can take to respond to both emergency and non-emergency grievances.

Action Tip Some health plans may have a form for you to fill out to describe your concern or complaint. Call the customer service number listed in your EOC or SPD to ask.

Making your case. If you decide to file a grievance or to appeal a decision made by your health plan or medical group, it is important to make your case as strongly as possible. For example, letters from your doctors, copies of articles from medical journals, or treatment guidelines can help support your position. Be sure to include copies of your personal records, including notes from conversations with your doctor, medical group or health plan, with your appeal. Refer to the Health Rights Hotline Action Guide "Information to Support Your Appeal."

Action Tip If you have received a bill for services that you don't think you should have to pay or if you have any other documents that relate to your problem, make photocopies and include them with your complaint. Remember to keep the originals.

Response to your grievance. You should expect a written response from the health plan acknowledging your complaint and describing what the health plan will do to resolve it. You should be advised in writing of the health plan's decision. This response should tell you what was granted or denied and why. You should also be told what to do if you wish to appeal a decision you feel is not fair.

Action Tip If you have an emergency, the health plan is required to resolve your complaint quickly. Check your EOC or SPD or call your health plan's customer service department to find out how to ask for "expedited review" of your complaint or grievance.

Most health plans are required to resolve consumer complaints within thirty days or less, depending on the issue. You have additional rights depending on the type of plan you are in or if you get your coverage through Medicare or Medi-Cal. Refer to the Health Rights Hotline fact sheets "Appeal Rights in Medicare Health Plans" or "Appeal Rights in Medi-Cal Health and Dental Plans" for more information.

Appealing a Decision

You may request a review of any decision. In some cases you may be able to appear before a committee that will hear your case. You may have to file a written request, usually within a limited amount of time from the date you received the letter from the health plan or medical group advising you of the decision.

Action Tip Make sure you understand the health plan's procedures and meet the required deadlines. Some health plans have very specific rules about how soon after they respond to your complaint you must appeal or take another step. If you do not understand the procedures, ask a customer service representative to explain them to you.

If an appeal meeting is part of your health plan's process, ask if you can bring someone with you to the hearing to help you present your appeal, such as a friend or attorney. But remember, this is not a court of law and the procedures are informal. You will be asked to present your case in your own words in front of the health plan's committee. In addition, you will have to respond to their questions.

Action Tip You have the right to know who will be present at an appeal hearing and who will make the decision. Ask your health plan. Depending on the issue, you may want to consider having your doctor attend the hearing or prepare a letter in support of your position.

When is a Decision "Final?" - Binding Arbitration and the Legal Options

Many plans use a procedure called "binding arbitration" as the last step for the resolution of grievances, appeals and claims. In most cases, you will have signed an agreement to follow this procedure when you signed your enrollment application. Binding arbitration means that the decision of the arbitrator is final.

Whether or not you have an arbitration agreement, you may have additional legal rights if you disagree with the health plan's decision. While it is probably a last resort, you may want to get an attorney to represent you and take your case to court.

Your rights as a health care consumer depend on the sort of plan you are in and who pays for your care.

Refer to the Health Rights Hotline Fact Sheet on "Resources to Help You Resolve Your Health Care Problem" for information on where to get additional assistance.

Call the HEALTH RIGHTS HOTLINE

Health care coverage can be complicated, but you do have rights. The HEALTH RIGHTS HOTLINE can assist you personally if you live in one of the following California counties: El Dorado, Placer, Sacramento, or Yolo. The HEALTH RIGHTS HOTLINE is a totally independent, free service which provides information and assistance about your rights as a health care consumer. Trained counselors will answer your questions and help you resolve issues with your medical group or health plan. If you need assistance, give us a call.