<%@LANGUAGE="VBSCRIPT" CODEPAGE="1252"%> Avoid Healthcare Denials and Delays
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            Denials and Delays
Understand Healthcare
Preventing Trouble
Handling Situations
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Insurance Issues
Power Philosophy

The first available appointment is two months away. Only the doctor's assistant is available. Your tests were not approved. Your case has been controverted. Your disability payment is not authorized. Your treatment was denied.

There are too many verses to this song. Delays and barriers to your healthcare are not just frustrations you need to wait out. They are threats because your illness can become more severe and harder to correct. And, the hardship to you and your family can worsen your health and psyche.

These problems are due to flaws in the system, and your best hope is to work to counter them. But you have to be vigorous. Below we discuss specific challenges such as insurance. But two common keys to these problems are your records and your doctor. Why records? Because they usually count for more than what you yourself say. They are being analyzed, fought over, and dissected for some specific phrase to support someone’s argument. If you don't have your records and read your records, beware.

Your records are closer to your property than anyone else's, and you should always obtain them after visits or treatments. You don't need to know all the terminology, but at least know what you said and were told at your meetings, and check that. Then work to learn the medical language and understand it by asking good questions. Should the records be inaccurate, how can correct decisions be made about you? If they are critical of your case, how can you know to answer the criticisms with other opinions if you are unaware of them? And don't assume each doctor or assistant will have all the records, because many regulations and bureaucracy rules make it unlikely your physician has all your records. It is best to bring your copy with you to complete their file.

It is obvious that your physicians are key to your health. They not only have to be good, but able to focus on your problem and give you adequate time. This is a very difficult challenge in modern medicine where time is compressed and resources overstretched. We all wish this were not so, but it is a substantial problem. It is better to work to counter it than ignore it. You need to balance the scales in your direction. In order to do this, first communicate your involvement to your physician. Be informed, ask questions, and again read your records. This will help him them see they need to focus on you. Secondly communicate your need for enough time and education. You may be swimming upstream here, but it is better than drifting. If your physician cannot meet your needs, look carefully for another one. Busy doctors with weak medical records can make misleading conclusions. These can ripple through all your medical care and health coverage. You need capable physicians who give you the focus you need, and make your case in their records. Finally, they have to take the extra effort to fight for your tests, treatments, and coverage. This is another burden in an overburdened day for most of them, but it is still vital to you.

Now you have prepared the ground properly. It is time to address some specific types of challenges.

1) Insurance:
This is complex because it varies with each policy. So read your policy and get help understanding its technical language. At this stage, hopefully before medical care is a pressing need, consider if you need an additional policy. Work policies may not be able to cover everything because not all illness occurs at work. So some additional coverage, perhaps by a supplemental policy or spouse's policy is important. Be aware that fights about whether all your illness is due to something the policy covers are common. That second policy can allow you to get treated while the insurance companies argue for months or years about what percentage of the problem is whose responsibility.
Beyond the policy, there are important common issues, and again the first is what is in your records. Then be sure to establish your contacts in the insurance company. You probably have a case manager, someone assigned to your case. This person can be very helpful, or seem to be an obstacle. But try to work with them as fully as possible. If you have problems in care, look to meet them. Sometimes they go with you to physician appointments.
If your approval is stalled, getting a second opinion from a specialist in your problem is a powerful help.
This may sway the insurance company, but is also going to help other allies you enlist. If that is not effective, you may need allies. A lawyer can often help, but the companies often are used to dealing with them and the compensation for the attorneys is often low. So while this is important, it is not always the solution. Another ally is your elected representatives, state or national. And the chairman of the state legislative insurance committee can be a great help even if not from your district. It does not matter if you voted for them. Just try to put your case together in a clear way, with your second opinions supporting your positions. They need this to be convinced of your case and to have ammunition to be effective in fighting for you.

2) Workman's Compensation:
Again these vary from state to state, and can also be federal or by industry. But in general three key questions will swirl about your claim.
a) Is your health problem a result of work covered by the policy ("causally related")?
b) Were there similar prior symptoms of disease processes that could have contributed to your illness?
c) What is the extent of your disability due to the work problem?
While a very large part of the determination comes from the records, an independent medical exam, one done by a physician directly or indirectly hired by the insurance company, is often done. It is not unusual for your physician to say you have one degree of causation and disability, and the IME doctor another. If so, an independent consult by a specialist can help make your case to the Workman's compensation company or some judicial resolution process. But be prepared for these matters to go slowly. So if you think the records leave any room for argument, getting the additional opinion helpful can save you a lot of time and effort.
Sometimes patients are very frustrated and angry at Workman's compensation or the IME doctor, but the determining statement about their disability came from their own physicians in their notes. Be sure to check for this.

3) Disability:
This is the extent to which you cannot work, or are physically limited in what you can do. There are AMA guidelines for this and a thick textbook (AMA Guidelines to the Evaluation of Permanent Impairment) to help with them. Not all states or insurers follow these, but the principles are usually similar. Key issues are how much of your disability is related to a particular event or coverage period, but also what your remaining work capacity is. Can you work with limitations in lifting or bending, for instance? Can you be retrained? And many insurers will pay for retraining. Disability rating is going to affect you pay while ill, and long term compensation as well.
Ratings are usually temporary if you are still in treatment or still improving. But once you cannot be treated any further, or have stopped improving, they can become permanent. It is not unusual for the temporary rating to be somewhat more generous that the permanent to give you some leeway for healing without extra stress. So a temporary permanent disability may become a permanent partial disability, at times.
In order to establish disability in a difficult case, a special test called a Functional Capacity Evaluation, or FCE, may be done. This is usually carried out by a physical therapist or rehabilitation group, with a formal rating of what you can do after a few hours of tests. It is important to take this test seriously as it carries substantial weight.
If you do not feel you have been rated in disability appropriately, read the records carefully, and check your second opinion. Legal and legislative help in appeals is often helpful, as with insurance and workman's compensation coverage.

© PowerPatient, FIND, 2003, 2004