How to Challenge an HMO's Denial of Coverage

By eHow Health Editor

Rate: (3 Ratings)

It's not unusual for a health maintenance organization, or HMO, to deny a treatment or test. When this happens, it's worth the effort to fight back.

Instructions

Difficulty: Challenging

Things You’ll Need:

  • Portable Tape Recorders
  • Notebooks
  • Pens

Step1
Enlist your primary care physician (PCP) in your fight. In many cases, he or she is the gatekeeper to medical services.
Step2
Start a logbook to document every telephone communication with your HMO and doctors.
Step3
Include in your logbook the name, number and address of the person you talked with, the date and time of the phone call, who initiated the call, and what was said.
Step4
Make it clear to every person on the phone that you're keeping a log.
Step5
Follow up the most important phone calls with written letters recapping what was said. Send CC copies of these letters to your PCP and your attorney, if you have one.
Step6
Keep copies of all correspondence you send and receive. Note the date that you received the mail, and keep the postmarked envelope if you believe the date may be relevant.
Step7
Take careful notes in all face-to-face meetings with doctors. Make it obvious - use a large pad of paper and write your notes contemporaneously (not afterward from memory).
Step8
Consider tape recording phone conversations and medical meetings.
Step9
Enlist the help of your congressional and state representatives.
Step10
Contact an attorney who specializes in medical matters, if all else fails.

Tips & Warnings

  • Make sure your physician uses the phrase "medically necessary" when referring to the treatment you need.
  • HMOs are regulated by your state's department of insurance.
  • It's illegal to tape a conversation without the other party's permission. Be sure to ask.

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eHow Article: How to Challenge an HMO's Denial of Coverage

eHow Health Editor

eHow Health Editor

Category: Health

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