Joseph Romano Law

Managed care was created by the health insurance industry to allow them to control costs by limiting the consumer's access to services. In the traditional form of health insurance, a consumer pays the bill for each visit. This type of insurance is called "indemnity insurance". In a managed care insurance plan, the purchaser (patient or employer) pays a set fee, and the managed care organization takes responsibility for providing whatever health services may be needed, regardless of cost. Managed care patients are not permitted to go to a hospital or see a specialist unless they first receive a referral from the primary care doctor. The primary care doctor acts as a "gate-keeper" and is responsible for monitoring the total medical care of each patient assigned to him or her under the plan.

Managed care advocates argue that aggressive preventative medicine will result in lower medical costs. Many doctors and health care advocates have concerns about the quality of care provided by a managed care organization. In a managed care system, many have argued that patients have become "covered lives", and healthcare services have suffered. Physicians and other health-care professionals are joining with consumer groups, healthcare advocates, and attorneys for the catastrophically ill and injured, in calling for a "fairer system", which would be cost effective and still provide for the short-term and long-term medical needs of the individual.

Obtain and carefully read the health insurance policy which defines your health insurance coverage;
Provide the health insurance company with the requested medical records, but do not give the health insurer or the managed care agency unlimited access to your medical records;
Verify health insurance coverage in writing - do not rely on telephone conversations with clerks;
Ask the physician if he or she has a financial incentive under a contract with the managed care insurer;
Work with the rehab nurse assigned by the managed care insurer, but remember, he or she represents the insurance company, and is also trying to represent you;
Beware of roadblocks erected by the managed care health insurer to deny benefits for the catastrophically ill and injured. These roadblocks are: The precertification process, peer review, exclusions, limitations, definitions, and experimental clauses in the insurance policy;
Just because a health insurer requests a medical examination, it doesn't mean they are legally or contractually entitled to it;
Never go to an "independent medical exam" (IME) for your health insurer, worker's compensation carrier or Social Security Disability without having an advocate, attorney, or family member with you;
Be aware that obtaining health insurance benefits from a managed care insurer is an adversarial process;
If a loved one or family member is catastrophically ill or injured, hire an health care intermediary, a personal medical advocate, or an attorney.

"The laws assist those who are viligant, not those who sleep on their rights." This legal maxim could never be truer than in today's world, when the health insurance industry is arbitrarily denying needed medical and rehabilitation benefits. You must contact an attorney or advocate who will fight for the benefits to which you are entitled.