My advice on how you can influence the authorization process is not lengthy, because there are only several avenues open to you within the system. To be successful, however, you may need to be persistent.

  • Speaking directly with your primary care physician or the care provider is a fair and logical starting step, since a simple and satisfactory remedy may be found. After that first step, there are other avenues you can pursue.
  • Each medical provider group and each insurance plan has its own UR nurses, physician UR director and/or medical director.You can call your group or insurance company and ask for them directly. You can also write to them if you have difficulty getting through on the phone. You may need to be very persistent.
  • Medical groups usually have a physician president or head of the group. Insurance groups have a CEO (chief executive officer) and possibly a COO (chief operating officer). These people want to maintain a highly respected image for their company or group and they may take strong action to resolve your complaint. You can call your medical group or insurance plan and ask for the names, titles, phone numbers and addresses of whomever you want to contact. Addressing your letters “personal and confidential” may help them to reach the addressee directly.
  • If you got your insurance through your employment, talk with your benefits manager at work. These personnel are the ones who choose the plans your company will offer employees. Since insurance companies want to continue to be selected when the plan comes up for company review, the benefits manager may be able to influence a decision.
  • All insurance companies and many medical provider organizations and hospitals maintain consumer affairs departments, ombudsmen (patient advocates) or social service departments that you can contact with requests and complaints.
  • Insurance companies, hospitals and medical groups all have quality care departments (QA, QI, etc., here is some more of that new language of insurance) whose purpose it is to investigate and respond to medical care questions and complaints.
  • Outside your insurance plan and care provider group, there are consumer advocate groups and legal regulatory agencies (i.e., the Department of Insurance in California) that you can contact in extreme cases.

In other words, you have many avenues of recourse should your managed care plan fall short of its own, or of your, ideals. It is valuable to investigate and use them when choosing an insurance plan or medical group. No one is more interested in or affected by the care you receive than you are.

Learning to advocate for yourself within the healthcare system is a powerful way for you to do self-care and enhance your prospects for recovery.

See also…

Labor and Employment Law

Healthcare Law – Forum

Insurance Issues – Forum