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Insurance Confidential: Insider Says Knowledge Is Power

Network - Spring 2010

By Mary Brolley

It’s complicated. Ricki Hasou is the first to admit that.

Hasou has seen the health insurance game from both sides. After a long career with a major insurance company, she joined M. D. Anderson in 2007 as a senior managed care analyst in the Department of Managed Care.

Since then, she’s helped M. D. Anderson patients figure out how to deal with their managed care plans.

For cancer patients who have insurance coverage, keeping up with the paperwork from their insurance carriers and health care providers is daunting. But Hasou offers a few simple strategies to make it easier.

Organization, record keeping essential

While Hasou admits she doesn’t have all the answers, she specializes in helping people learn when and how to ask the right questions.

“There are general guidelines that will help you navigate your insurance coverage,” she says. “Know your policy, ask questions when you don’t understand and learn how to appeal a denial. And write it all down.”

As many patients have discovered when they’re dealing with an onslaught of mailings and e-mails from providers — especially during a long or protracted illness — it’s nearly impossible to remember whom you called, what you discussed and exactly when.

Yet, because these details may help build or support a case, it’s crucial to track them in a notebook or maintain notes in a file.

Knowing your policy means reading the materials sent or provided when you enrolled. Take your time, read through it, figure out what type of coverage you have.

First, define the terms

Hasou spends a good bit of time explaining the terms for the most important elements of your coverage. Is your provider an HMO (health maintenance organization) or a PPO (preferred provider organization)? Does your plan offer in- and out-of-network coverage? If you receive care outside your network, what are the financial implications?

And if your child is the one seeking care, which parent is considered the primary insurance holder?

Beyond that, there are questions about the necessity of referrals from a primary care physician and/or a need for authorization for specific treatments.

Many patients consider traveling to Houston to be treated at M. D. Anderson, so in- and out-of-network benefits are one of the largest areas of concern. Every day, Hasou’s colleagues in Managed Care and in the Department of Patient Access Services go to bat for those who want to be treated at M. D. Anderson. Physicians and their staffs are also accustomed to stepping in to help assure coverage.

One of the most helpful resources is the health plan’s case management department, Hasou says. It works with patients and providers to confirm whether a certain treatment will be covered by your health plan before any costs are incurred.

Your insurance card yields insights

In her teaching role, Hasou goes step by step through an enlarged picture of a typical health insurance identification card. Though this may seem simple, it provides a good deal of information and is essential to getting anywhere.

The card contains identifying information about the cardholder and the policy, including co-payment amounts.

Perhaps the most important information of all, however, is on the back of the card — the address of the provider’s Internet site and its customer service phone number.

Customer service personnel: your allies

Hasou insists that the staff of the insurance company’s customer service department is or should be the patient’s or caregiver’s friend. “The person who answers the phone is your advocate,” she says. “He or she is there to help you.”

Hasou’s advice? Take a deep breath. You’ll likely have plenty of time to do so while you’re on hold. Then, she advises, be polite but persistent.

“Ask away. It’s OK to question a charge or a denial of coverage. If you’ve been refused, stay polite and businesslike. Ask how you can appeal the denial. There’s a process for all of this,” she says.

When you appeal an insurance carrier’s denial of coverage, it’s important to follow the guidelines to the letter. Find out who should receive the appeal. Attach all requested documentation. And make copies of everything for your files, just in case.

The nonprofit, nonpartisan Kaiser Family Foundation has an Internet site that includes helpful and practical information about health insurance policies, including a printable checklist on which to record the basics of your plan.

Knowledge about your insurance coverage really is power. Wade in.

© 2015 The University of Texas MD Anderson Cancer Center