Becoming Your Own Patient Advocate

I would describe myself as a persistent patient. Others might describe me as a pesky patient.

Living with Parkinson’s Disease and Deep Brain Stimulation, I’ve needed to become my own patient advocate. I’d like to share some of the lessons learned along the way.

Select a Neurologist

Select a neurologist that has the experience and expertise that meets your medical needs. It’s also important that you choose a provider that you feel comfortable with and one with good communication skills. With Parkinson’s, consider selecting a neurologist who is a Movement Disorder Specialist.

Some health care plans allow patients to have “get acquainted visits” with a prospective provider. After meeting with the prospective provider, if you are uncomfortable, trust your instincts. If you have concerns about the competency of the prospective provider, you may also check out the status of the provider with your state’s Department of Regulatory Agencies to make sure there are no disciplinary actions. It is a matter of public record.

Know Your Coverage

Read the Evidence of Coverage booklet to determine what benefits are covered and not covered by your plan as well as the amounts you will be required to pay when you use health services. Before receiving services, contact your plan to make sure that the services are covered.

Deal with Disputes

If a dispute develops, contact your provider’s office and try to work out the problem. Some health care coverage issues can be resolved with a simple phone call. If this doesn’t result in a satisfactory solution, call the health plan member services department to obtain clarification of the policies and procedures of your plan.

If you remain dissatisfied, call the patient representative and/or risk manager to set up an appointment to discuss the disagreement.

Denial

Analyze what led to the denial of coverage and the insurer’s procedure for appeals. Call the customer service department and find out why the claim was denied. Talk to someone who can provide a clear answer.

If the insurer tells you it is not their error, but something your doctor or hospital can correct, call them and determine if it can easily corrected.

It is important to have the denial in writing. Obtain a copy of the denial letter.

Obtain a copy of the Evidence of Coverage booklet.

After you gather the facts, develop a strategy.

Consider getting assistance from a nonprofit patient advocacy group.

Be Prepared

Set up a binder to file the Evidence of Coverage booklet, bills, physician information, referrals and copies of all correspondence and paperwork about your health insurance problems.

Prepare a spreadsheet summarizing and documenting your efforts to resolve the problem, e.g., name of contact, title and position of contact, date of contact, time of contact, method of contact (phone, email, in person, fax, by mail) to use for future reference, if necessary. Also include details of the discussion.

Appeal

You can appeal a decision rendered by your health plan. The appeal process is included in your Evidence of Coverage booklet. Most likely, you will be required to file your appeal within a specified time period. It is essential that you meet these deadlines.

There are two methods of appeal: internal and external. The internal appeal is to the insurer itself and is the first step in the appeal process. If you are dissatisfied with the results of your plan’s initial review of your appeal, your plan may have a second level of appeal.

If your appeal is again denied, your health plan will tell you how to file for an independent external review. An external appeal is filed to your state department of insurance or other governing body and are is filed when internal appeals have been exhausted.

If you are dissatisfied with the results of an independent external review, you may want to consider a consultation with an attorney to determine your legal rights and options.

Fortunately, I did not have to go through the entire appeal process to reach a resolution. It took a lot of energy and determination to become my own advocate, but I am now reaping the benefits from being a persistent patient.

“Don't be discouraged.  It's often the last key in the bunch that opens the lock.”  ~Author Unknown

Comments

[Crystal Fornes, NP, RN]

Hi Ms Kelsall,
I was so happy to read this post. You embody what EVERY patient should be doing...taking the initiative to become knowledgeable about his or her diagnoses and advocating for the best possible care and coverage. If that means being labeled as "pesky" so be it! In the end, it is your health that matters. Thank you for sharing some of the lessons you have learned along the way.

Crystal Fornes
www.bluecompasshealth.com

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