How to Challenge an HMO's Denial of Coverage

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

1. Enlist your primary care physician (PCP) in your fight. In many cases, he or she is the gatekeeper to medical services.
2. Start a logbook to document every telephone communication with your HMO and doctors.
3. 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.
4. Make it clear to every person on the phone that you're keeping a log.
5. 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.
6. 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.
7. 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).
8. Consider tape recording phone conversations and medical meetings.
9. Enlist the help of your congressional and state representatives.
10. 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.