After successfully navigating your choices among health plans and picking a plan that best suits you and your family’s needs, some consumers may be faced with other issues that could potentially compromise timely access to treatment or increase out-of-pocket costs. These issues include: finding the right primary care physician (PCP) and determining if your provider at the hemophilia treatment center (HTC) is in-network and has the specialty pharmacy provider worked with your current insurer. Unfortunately, understanding what to do and who to contact in these situations is not always clear.
To determine the source of the problem, you must first ask the right question to the right person. For example, if you are experiencing problems with your PCP effectively communicating with your HTC about questions regarding your treatment regimen, ask your HTC who would be best to facilitate this type of interaction. Most likely this is an education issue about ensuring that all members of your treatment team, including your PCP, are educated about your bleeding disorder and any other health issues you are having. Changing health insurers sometimes involves changing your PCP, which may involve a certain amount of trial and error before finding the perfect fit. But once all the providers are on the same page, they can advocate on your behalf when other questions or concerns arise.
If you get a claim from your insurer stating that your recent HTC visit was not covered, we suggest calling your insurer to help figure out whether this is a simple billing error or something more, like a change in your plan’s network. This and all subsequent calls and communications should be documented, including the date and time of call, as well as the person you spoke to, should any further action from the plan or provider be needed. If you have any questions or there is something that is not being adequately addressed or is still confusing, ask to speak with someone else. Then document that conversation the same way. Treat each conversation as an opportunity to educate someone who is not familiar with bleeding disorders.
Documenting each and every interaction, including what was discussed, what progress was made and the proposed next step, is important for your own protection. This information, as well as any explanation of benefits (EOBs), claims, and/or denials, will assist in the process if filing an appeal and/or grievance is required. NHF believes that asking the right questions, and educating health plan insurers and providers may take some time but will only get easier as your relationship with your insurer and/or healthcare provider grows.
Read NHF’s fact sheet on insurance appeals and grievances.
