Greensboro News Record (May 23, 11:43 PM) When Mark Cooper's doctor left Winston-Salem for a Clemmons practice, Cooper checked with his health insurance company, Cigna, to make sure his doctor was still in its network. He was, Cooper was told, so he began trekking to Clemmons to see the doctor.
Everything was fine, until Cooper started getting bills from the doctor's office. Cigna wasn't paying. Then Cigna told Janet Cooper it had dropped her husband's doctor from its network.
"I said, 'OK, that's not what you told me at first,' " she said. The Coopers spent months arguing with Cigna, before they finally stopped hearing from the company. "We thought everything was taken care of."
It wasn't. The next call about the medical bills was from a High Point collection agency.
Insurance company executives and state and federal officials say problems like the Coopers' can often be avoided entirely, but when they can't, there are ways to get help.
An ounce of prevention
Insurance executives and government officials say consumers should review their health plan's benefits before using them.
"It's important that customers do what they can up front to learn what their insurance covers," said Mark Stinneford, a spokesman for Blue Cross and Blue Shield of North Carolina. "They should get, each year, a benefits booklet, and that contains detailed information on their coverage - things that aren't covered, what portion they can expect to pay ... It's something you should review carefully when you get it."
Consumers should also check their benefits before getting a service for the first time. Health insurance doesn't guarantee that any medical service that consumers want, or even need, is necessarily covered. Different policies provide different levels of care and different benefits.
Insurance providers typically have customer-service phone lines and Web sites where customers can get more information. Cigna's Web site, for instance, can help consumers figure out if their doctor is in the company's network, what the co-pay is for a certain drug, even which hospital is best for certain medical procedures. There's also an information line staffed by nurses.
None of this applies if it's an emergency.
"If you're having chest pains or severe shortness of breath or you think it's a medical emergency ... don't wait," said Scott Josephs, Cigna's market medical executive for the Carolinas. "I think you'd be hard pressed to find a situation where I think any insurer didn't cover the emergency."
Internal appeals
Insurance companies, as well as employer-funded programs, such as the one state employees have, usually have an internal appeals process consumers can turn to if a claim is rejected.
Many claim disputes are the result of clerical errors or other easy-to-fix problems and can often be handled with a phone call to the insurer's customer service line, insurance executives say.
"Your first line of defense with regard to any kind of concern or disagreement is to call the customer service number," Stinneford said.
Cigna and Blue Cross and Blue Shield both have a two-stage internal review process.
In Blue Cross and Blue Shield's case, for instance, a panel of physicians might review whether a particular procedure is medically necessary, Stinneford said. Customers can attend those meetings, bring along a lawyer or someone else, submit information and question the review panel.
After internal appeals are exhausted, sometimes the government can help.
Calling Uncle Sam
Health insurance plans generally fall into two categories: fully insured and employer funded.
In employer-funded plans, the employer agrees to be responsible for the plan's health-care costs, even though an insurance company may still handle the day-to-day management of the plan. These are usually regulated by the federal government.
Consumers can ask their human resources department or call the plan's customer service number to see what kind of plan it is.
"More and more of our inquiries do relate to health benefits and claims resolution," says Gloria Della, spokeswoman for the Employee Benefits Security Administration, the federal agency that regulates most employer-funded plans. "We essentially can't do any more than help them get what they're entitled [to]."
But the agency can help consumers understand their rights under federal law.
"If there's no issue or they just don't understand something, they can call," Della says.
Della also recommends consumers challenge health plan decisions in writing, which forces health plan administrators to respond within a certain time.
Disputes are often resolved by the EBSA reminding health plan providers what their obligations are under law, Della says, and sometimes even under the terms of the health plan.
Going to the state
Two state government offices can help consumers who find themselves fighting the insurance company, sometimes offering advice, sometimes intervening on consumers' behalf.
Fully insured plans, as well as the state employees' health plan, are subject to state regulations. Since 2002, the Department of Insurance has run a Healthcare Review Program that can order insurers to submit to binding reviews.
The program deals primarily with questions of medical necessity, where the insurance company agrees the disputed service is part of the health plan, but doesn't think it's medically justified.
"The insurers are required by statute to notify the consumer of their right to request an external review when they issue a noncertification denial," says Susan Nestor, the program's director.
A panel of independent physicians and health-care providers reviews each case and decides whether the treatment is medically necessary. If the panel agrees with the consumer, the insurance company pays.
In 2003, the program received 220 requests for review and reviewed 90. In 49 cases, the agency upheld the insurance company's decision. In another 40 cases, the insurance company was required to pay for the service. In one instance, the insurance company reversed its denial before the independent panel reviewed it.
Besides the Department of Insurance, the state attorney general runs a Managed Care Patient Assistance Program. The agency can advocate on behalf of consumers.
"Anyone who has ever had to deal with a managed care problem can tell you how frustrating it can often be," said Attorney General Roy Cooper (no relation to Janet Cooper). "We're seeing a steady increase now in contact from people as more and more people are finding out about it."
In 2003, its first year of operation, the office handled more than 1,500 phone calls. Including one from Janet Cooper, whose dispute with Cigna had turned into a months-long ordeal.
How the Coopers coped
"They did a lot of the legwork for me, calling the insurance company," Janet Cooper said.
It took months before the dispute was settled. After a while, Cooper's husband switched doctors, to someone they were sure was in Cigna's network.
"We struggled with (Cigna) off and on for quite a while," she said. "They did go back and find out that when they terminated his physician from the network was after my husband quit seeing him, so in essence they should have been paying him all along."
In the end, Cigna agreed to pay most of the disputed bills. The Coopers still paid about $175, but that was easier to handle than the entire $700 debt.
Cigna spokeswoman Amy Turkington said federal health care privacy laws prevented her from commenting on the Coopers' situation, but that the company is committed to providing responsive customer service.
"We do encourage members to contact us when they have a concern," she said. "We also encourage members to use the appeals processs that is provided under their plan."
Still, the Coopers are unhappy with Cigna. This year, the only health insurance plan Janet Cooper's employer offered with the benefits she wanted was from Cigna.
"When I saw who it was, I just wanted to cry," she said.
She hasn't gone to the doctor this year - yet. After her husband's battle, she said, she's "dreading it."
Contact Mark Tosczak at 227-6380 or mtosczak@news-record.com
