Editor's note: You've tried to handle a dispute with your health plan on your own, but they won't budge. Is there anyone who can give you a straight answer?
Well, it turns out that the state of California employs attorneys, nurses and analysts in the Department of Managed Health Care's Help Center to solve problems with your managed care coverage.
They offer assistance with issues ranging from difficulties getting an appointment to timely referrals to specialists, from denial of a doctor's recommendation for treatment or medication to an incorrect medical bill.
We can't promise things will always go your way, but you will get the attention of state regulators who know your legal rights.
I was diagnosed with a rare disorder in 2003, and it progressed to the point that there was no standard "next step" for treatment. The disease has spread to my lungs, and I have to use oxygen just to continue to breathe. A clinical trial at Northwestern University showed potential benefits for people with my disorder by treating it with a stem-cell transplant. However, I belong to Kaiser, an HMO, and according to my contract, they won't pay for me to participate in a medical trial because it is not being conducted in the Kaiser network. Is there anything I can do? – Victoria Chavez, Sacramento
Typically, you must receive health care from doctors and facilities that have a contract with your health plan.
However, there are times when it becomes medically necessary to go out-of- network to get care you need.
In this case, Victoria requested a treatment that Kaiser did not consider medically necessary, and it denied the request because it didn't agree that the transplant was the appropriate "next step." Consequently, if she elected to participate in the clinical trial, she would have to pay herself.
So she asked the Department of Managed Health Care for an independent medical review, which allows an unbiased, independent panel of doctors to make a binding decision as to whether the treatment was medically necessary.
The panel concluded that that the stem-cell transplant was medically necessary because it represented the most hopeful approach available to patients with this disorder. Because Kaiser did not have the services available in network, it was required to pay for her care in the Northwestern University clinical trial.
To ask a question of the Department of Managed Health Care, go to www.sacbee.com/ask or write Second Opinion; Features Department; The Sacramento Bee, P.O. Box 15779, Sacramento, CA 95852.
