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FamilyCareAmerica.com
This article is reprinted with permission of www.FamilyCareAmerica.com, a nationally recognized resource that provides families with interactive care planning tools, resource locators and helpful checklists to make caregiving easier. The company also provides corporations with a Work/Life program for employed caregivers. For more caregiving information, visit them on the Web.
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10 Managed Care Tips for Caregivers
www.FamilyCareAmerica.com
If you provide care for an elderly, ill, or disabled loved one, you've probably had to deal with his or her insurance company. Filling out the paperwork can be a time consuming and confusing process-especially if the company denies a claim. Luckily, help is available in many states through the office of the managed care ombudsman. These consumer advocates can help you understand your rights under different managed care plans and guide you through the appeals process.
The following tips were provided by The Office of The Managed Care Ombudsman, the Bureau of Insurance, Commonwealth of Virginia. Check with the appropriate office in your loved one's state for information regarding specific regulations.
- It's worth the time and effort to read and understand the documents provided by your loved one's insurance company. This includes evidence of coverage, as well as other documents such as member handbooks, provider directories, newsletters, and other material.
- Understand as much as you can about the plan before your loved one uses it. It's particularly important to know the primary care provider, the plan's policy regarding referrals to specialists, co-payment requirements, and access to emergency care. Be prepared. The plan will probably not cover all of your loved one's medical expenses, and he or she may have to pay part of the cost.
- Ask questions about anything that isn't clear.
- If you need assistance, contact the plan's representatives, your loved one's insurance agent, his or her employer, or the office of the managed care ombudsman.
- If a problem arises, you should first contact your loved one's managed care plan. The evidence of coverage contains a telephone number and mailing address. Be sure to record the day you call, the name of the person you speak with, the title of the person you speak with, and a summary of the conversation.
- If your loved one or his or her physician has difficulty obtaining approval for medical care-or experiences difficulty with a claim-know what your loved one's rights are according his or her particular plan.
- Follow the instructions provided by the plan to appeal any decision. Familiarize yourself with the levels of appeals and grievance procedures that are available through the plan's internal process.
- Carefully document-in writing-the facts that support your case. Keep your letters business-like and clearly state why you believe you are correct. Include copies of documents from your loved one's physician that support the appeal.
- Follow the time lines and meet the deadlines set up by the plan. Be sure to keep a copy of any letters you send.
- At any point in the process, feel free to contact your local office of the managed care ombudsman for assistance.
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