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When You and Your HMO Don't See Eye to Eye

Sometimes even managed care members are unpleasantly hit with unexpected charges from their health care provider.

WebMD Feature Members of managed care plans often say there's an advantage to paying a fixed monthly premium to cover most of their medical costs. They might shell out the occasional co-payment for a doctor's office visit or prescription medicine, but they generally face no major health care bills beyond the monthly premium (or their share of that premium if their employer pays some of it).

That's the way it's supposed to be, anyway. But sometimes even managed care members are unpleasantly hit with unexpected charges from their health care provider.

A Common Scenario?

You take a nasty turn on a ski slope while on vacation. On the advice of the ski patrol, you check in at the local emergency room to have your knee -- now the size of a small cantaloupe -- examined. You check into your managed care plan's hospital, assuming they'll cover just about everything but the long-distance calls to friends and family. Yet a month later you get the bill, which claims you owe much more than just phone charges. You get billed for services from the emergency room, the doctor and the radiology lab, plus in-hospital lab testing and X-rays that you thought would be covered.

Strategies for Success

What to do? Here's advice from consumer advocates:

Victoria Ross, a counselor at the Health Rights Hotline -- a pilot project in Sacramento, California -- helps consumers navigate their health care plans. Her advice in our hypothetical situation? First, find out if it's a paperwork mistake. If you've been billed for emergency room charges, call up the provider and be sure they have the correct information.

In many cases, she says, it's simply an error. Perhaps the emergency room clerk who checked you in was busy and marked you as uninsured, a mistake that prompted the accounting office worker to send the bill to your home address instead of your managed care plan's address.

So if you've received an unexpected hospital bill, call the managed care plan's business office to see if it's a mistake. Sometimes the laboratory or radiologist may be billing you, even though their services are covered, because your managed care plan has not yet paid them. Find out if that is the case.

If the extra charges are not a mistake and you're still expected to pay, review your plan's coverage information, Ross says. Determine if the services you're being billed for are actually covered benefits. If they are, bring it to the attention of your plan's member services department.

If the services you've been charged for are not covered -- but you think they should be -- you can still appeal the decision. "Ask for a review," says Mohit Ghose, a spokesman for the American Association of Health Plans, a Washington-based national trade organization. How to ask for one? Check your plan's coverage information or call the member services department. Every managed care plan has an internal appeals process.

As you work your way through the problem, you will no doubt make several telephone calls to your managed care plan's offices. On the first call, ask the representative you speak with for his or her name and telephone extension, suggests Mary Jo Payne, a spokeswoman for California Health Decisions, a nonprofit advocacy organization in Orange, California. Then on future calls, ask to deal exclusively with that person. You'll avoid having to repeat your story a dozen times.

Ounce of Prevention

To help avoid future problems, consumer advocates suggest you develop a few common-sense habits. When you call your health plan to authorize services such as out-of-area care, always get the name of the person you talked to and the time and date. Jot down the gist of the conversation.

If you received medical care out of your plan's area and don't see any paperwork after a month, don't assume no news is good news, Ross says. "You want to be sure the bill was paid in full," she says. Call your health plan's offices to see if it was paid. If your provider hasn't gotten a bill, call to be sure the provider or the hospital and doctors aren't waiting on payment from you, possibly jeopardizing your credit.

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Last Editorial Review: 1/30/2005 10:44:24 PM