Tips to redress health insurance plan problems

Nov 24 2009

If you have a problem with your health insurance plan, there are steps you can take to get the service you need. California's Office of the Patient Advocate encourages Californians to speak up if they are having problems with their health plan and report any complaints. Start by explaining your problem to your doctor and your health insurance plan. If this doesn't resolve the problem, file a formal complaint with your health insurance plan. You can file a complaint by letter or e-mail, over the phone, or on your health plan's Web site. If you are still not satisfied, contact the Department of Managed Health Care's Help Center at www.HealthHelp.ca.gov or 1-888-466-2219.

If you have a problem getting the care you need from your health insurance plan, the Office of the Patient Advocate offers these tips for talking to your health plan:

-- Act promptly. -- Be persistent. -- Take notes on your calls. -- Get the names of people you talk to. -- Have someone with you for support. -- Ask to speak to a supervisor. -- If you are denied care, ask for the reason in writing.

"You may experience some frustration with your health insurance plan. It is up to you to report any problems you have in getting the health care you deserve," said Sandra Perez, Director, Office of the Patient Advocate. "To help prevent and resolve problems, contact the Office of the Patient Advocate for resources that will help you receive quality care."

To help you file a formal complaint with your health insurance plan, the Office of the Patient Advocate provides the My Complaint worksheet that is designed to keep track of important information when submitting your complaint. The Office of the Patient Advocate also provides resources and tips on how to talk to your doctor and health insurance plan about your problem and where to find local help with your complaint for both HMOs and PPOs. This information can be found on the Office of the Patient Advocate Web site: www.opa.ca.gov.

Patients who have urgent health problems or already filed a complaint and are not satisfied with their health plan's decision are encouraged to contact the Department of Managed Health Care's Help Center. The Department of Managed Health Care makes sure that health plans follow the law and address member complaints on time. The Help Center will review your complaint, decide if your health plan is in compliance, and will require health insurance plans to act if the decision is in your favor.

Health care plays an important role in the lives of all Californians. The Office of the Patient Advocate seeks to provide Californians with the information and tools needed to make informed health care decisions and get the most out of their health insurance plan. In addition to free educational materials, the Office of the Patient Advocate releases an annual health care quality report card rating the largest health insurance plans and doctors' medical groups in the state on quality of care and patient satisfaction as rated by members of the plan. There are also easy links to report cards on hospitals, nursing homes, PPOs, Medi-Cal, Medicare, and Healthy Families.

The Office of the Patient Advocate is an office in state government established in 2000 to inform and educate Californians about their rights and responsibilities as health insurance plan members and to teach them how to get the most out of their health care. To learn more about getting the most out of your health care, or to download health worksheets and other health care-related tools, visit www.opa.ca.gov.