family health insurance help

I’m used to the fight. When my doctor diagnosed me with TMJ/TMD, I had to battle my insurance company to get coverage because it did not consider TMJ/TMD a chronic illness. I successfully challenged my health plan to get the treatment I desperately needed. It was then I decided no one should have to go through this process alone.

That is why the California Chronic Care Coalition (CCCC) launched the My Patient Rights (MPR) website. We want to help people who are dissatisfied with the decisions made by their health plan. Our goal is to make it easier for patients to reach the appropriate state agency to obtain information quickly, file a complaint if necessary, and get the medical treatment they need.

MPR helps people who experience a range of barriers that may include denials to important procedures, barriers to prescription medicines, medical bills from out-of-network providers, delays receiving tests for chronic diseases, denials to specialists, and other billing issues.

Patients in 17 states, soon to be more, can use MyPatientRights.org to find links to their health plan’s complaint formswhere to go to file a complaint with their state’s regulatory agency, and ultimately share their story. By sharing their story, or that of a loved one, they help highlight recurring health care barriers that place other patients at risk. They help bring awareness to particular problems so other patients won’t have to suffer the same denials, delays, and anxiety.

My Patient Rights places a high priority on ensuring that personal healthcare information remains confidential. Patients don’t have to include specific health-related details in their story, but instead, explain how denials or delays to healthcare treatments or services have affected their health.

 

A wide range of problems

One of the most common reasons patients come to MyPatientRights.org is because their health plan denies certain medicines or treatment. Sue is a retired teacher who was paying $25 dollars per month for her prescription strength Nexium, which was successfully treating her stomach issues. Her insurance company notified her that her prescription was going from $25 to $850 a month unless she switched to a cheaper, generic medication. She tried the new medication for two months and it doesn’t work for her. Now, she has severe stomach cramping, can’t eat normally, and has lost 21 pounds. MPR is helping her file the correct appeals with her health insurance provider and the state so that she can get the affordable, effective medication she deserves.

My Patient Rights may share a portion of, or the full submission of, a story on this website so that others can learn about the problems a patient faced when accessing the quality, affordable health care they deserve. We will contact the patient first to get their permission before sharing their story.

Another common complaint we’re hearing from patients is with their coinsurance. That is the percentage of costs of a covered health care service you pay after you meet your plan’s deductible. Because insurers base coinsurance on a percentage instead of a flat copayment, coinsurance can be difficult for patients to predict. Insurers often assign treatments to a specialty tier with a relatively high level of coinsurance. Medications prescribed to treat complex chronic illnesses such as multiple sclerosis, cancer, rheumatoid arthritis, and Crohn’s disease are often placed on the specialty tier.

Some patients are facing continuity of care issues. Mary’s daughter needed to switch providers when she graduated from college and headed to medical school. Mary’s daughter requires medication for antibody deficiencies that cause chronic sinus infections and for arthritis. Mary made more than 30 calls and sent dozens of emails trying to get authorization so that her daughter’s medication wouldn’t lapse. The family could not afford $12,500 per month for the prescriptions. The new insurance company finally agreed to a specialty peer to peer authorization. Mary’s daughter was delayed two weeks on her medication. Luckily, the first year medical student didn’t get sick.

We’re seeing grievances from people with high deductible plans. Typically, the monthly premium is lower, but you end up having to pay more before the insurance company starts to pay (known as “reaching your deductible”). These plans can lead to financial hardship and thousands of dollars of out-of-pocket costs if you get seriously ill or injured. With a large deductible, you may have to pay full price for a costly test or medication.

MyPatientRights.org is also helping patients who have seen a provider outside their plans’ network. They may have unexpected charges if they’ve seen an out-of-network doctor during a visit to an in-network hospital. Sometimes your doctor or medical group leaves your health plan. Some health plans may not cover the bill or will only cover a small portion. Patients have certain rights and continuity is one of them.

Patients often don’t know they have a place to go for help if they are experiencing delays in their care. Prior authorization is when a health plan requires patients or their doctors to get approval from the health plan before treatment begins or before they can see a specialist. This is stressful, causes more trips to the emergency rooms, and negatively affects outcomes to delays in diagnosis and treatment.

Due to healthcare confidentiality, only a patient’s health insurance plan, medical group, doctor, or the appropriate contact at state regulatory agencies can assist in resolving a complaint or grievance. However, we do provide patients with the information they need to contact those who can help.

By channeling patients’ complaints through their state’s regulatory agency, MyPatientRights.org is informing decision makers about the pattern of issues, delays, problems, and denials individuals face in their state’s current healthcare system. The state agencies will motivate needed changes in the health plans and ultimately ensure affordable access to quality coverage.

 

A call to action

Join the CCCC as we broaden the reach of MyPatientRights.org and showcase specific access issues in each state. Help us explain to legislators, policymakers, and others what barriers to access exist. Sharing your story is an easy way for you to have a voice in your health care and directly impact change in the healthcare system for every patient.

Elizabeth Helms
Elizabeth (Liz) Helms is the President/CEO of the California Chronic Care Coalition, an alliance of nonprofit, social consumer, and provider organizations united to improve the health of people with chronic conditions or diseases. She co-founded the TMJ Society of California, a non-profit dedicated to bringing about changes in healthcare practices and laws to improve treatment for TMJ suffers. She is on the board of directors for the California Healthcare Performance Information System (CHPI) representing California's consumers and serves on many advisory committees including California Department of Public Health, Chronic Disease Division, The CA Endowment, Health Happens Here Partnership, UC Berkeley, School of Public Health – PCORI grant: "The Comparative Impact of Patient Activation and Engagement on Improving Patient-Centered Outcomes of Care in Accountable Care Organizations." She is also a committee member for the CA Right Care Initiative.

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