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Advice for Dealing With Your Insurance Company

Originally published on November 10, 2009
Most recently updated on April 10, 2013
  • Educate yourself. Know about your child’s illness and why referrals to specialists are needed. You will sound knowledgeable and thus will be more likely to quickly get the assistance you need.
  • Get a copy of your policy and review it carefully. See exactly what services are covered and how the payment system works. Be aware of lifetime limits (capitation) and see about purchasing additional coverage now, before it may be needed.
  • Ask for a case manager at the insurance company who will always handle your case and answer questions. Ideally you will find someone who is sympathetic to your case and time constraints. (Don’t waste time on someone who is not helpful or is uncooperative. Ask for a supervisor.)
  • Document every phone call. Write down the name of the person you speak to, the date and time, and the topic discussed.
  • Fill out every form completely. Payment may be delayed or denied if the required information is missing. You may want to send in claims “return receipt requested” to ensure that someone of authority will have to sign for it.
  • Many insurance plans and health maintenance organizations (HMOs) require that specialized tests, procedures, and treatments be pre-approved and authorized by a primary care provider (usually the pediatrician or doctor who provides routine medical care.) You may need this authorization when you call to make an appointment with a specialist.
  • Develop a good working relationship with the office staff of your child’s primary care physician because authorizations must come from there. Try to personally meet the person who will be handling these and discuss the whole case with him or her.
  • Keep a copy of every authorization you ever get! Follow up on authorizations and never assume that they are being handled. Consider telling specialists that you will get the necessary authorizations yourself. This may save money and problems later, because you are ultimately responsible for the bills.
  • Sometimes the referral process to specialists or therapies is slow. You may have to emphasize the serious nature of your child’s illness to get an earlier appointment or referral.
  • Don’t wait for someone at the doctor’s office or insurance company to call you back. (Staff members get busy. They forget. It isn’t their child.) Call back—every day if necessary. It’s possible to be both persistent and polite (even though you may feel otherwise after spending hours on hold).

You have a right to ask questions and to demand the best care for your child. Occasionally you may have to file appeals and grievances to obtain this care. Ask your child’s doctor to help explain complicated situations to the insurance company. You may get help from your state legislator to intervene with your insurance company so that your child can get the service for which you are paying insurance premiums.

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