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Re: depression and consistent bleeding
tinymom Views: 3,737
Published: 15 years ago
This is a reply to # 901,633

Re: depression and consistent bleeding

Dear mommiof4 and all who are having problems getting treatments that are needed by your doc: Dealing with doctors  Many people are intimidated by doctors, and find it hard to question them. But remember, it's your health! A good doctor will appreciate your willingness to take responsibility for it, and will encourage you to be an active partner in your own treatment. How to speak up. If you are clear, well-informed, polite and persistent, your doctor or other provider is more likely to discuss your case with you. If they say something you don't understand, ask them to explain in a way you can understand. Take notes! Or keep a medical log. You'll probably have more questions later. Be persistent. Since doctors in managed care plans often have limited time for each patient, getting answers may require an additional appointment, or even repeated phone calls. But don't give up. Your health is too important. Second opinions. If a doctor recommends major surgery or a therapy that concerns you, it's your right to seek a second opinion. Don't be intimidated. These days, most doctors understand a patient's need for a second opinion. If yours resists, insist politely. Or, if possible, find another doctor. Been denied?  Even if your doctor recommends a treatment, there's no telling if your plan will pay for it. Sometimes treatment is denied as "experimental" -- even when it's known to be the patient's best hope. Sometimes certain treatments are excluded by a policy. But consumers -- lacking medical or legal expertise, and unable to anticipate what treatments they might need someday -- are caught unaware when needed care is denied. You may be shocked and discouraged if your health plan denies treatment coverage. But don't give up. It's important to note that many health plans deny claims almost as a matter of routine, due to financial pressures. With knowledge and persistence, you may be able to have the denial reversed. How to appeal  The appeals processes of most health plans are pretty intimidating--so daunting, in fact, that 9 out of 10 patients give up before they go through the entire appeals process. Of course, when patients do give up, the health plan saves money! But you can end up paying--with your savings, your health or even your life. These tips can be helpful in getting your health plan to pay. 8 steps to Effective Appeals: 1. Get your policy. Get a copy of your actual policy, as well as all brochures and other documents that describe your benefits. Read them all carefully, and make notes of any words that seem to support your claim. 2. Follow the plan's rules. If the rules for appeals are not clear in your policy or other literature, politely insist that the health plan send you written procedures, immediately. Then stick to them. If you're forced to follow spoken instructions (in an emergency, for example), keep careful, written notes. Be sure to include the name of the person instructing you, as well as the date and time. 3. Learn the legal requirements. Your plan's rules aren't the only ones that matter! Contact your state insurance commission, HMO task force or other regulatory body, and learn what they say you should do to appeal a denial. 4. Make note of deadlines. This is part of following the rules. Miss a deadline, and you could miss out. 5. Note emergency exceptions. Many plans have different appeals procedures, and deadlines, for emergency situations. If you're facing a medical emergency, be sure to demand written procedures for emergency appeals. 6. Call before writing. Sometimes denials can be reversed with a phone call. Sometimes it takes multiple phone calls--as many as 10, or even more. (But keep those deadlines in mind!) Keep your cool. Remember, "honey catches more flies than vinegar." Besides, the denial may have come from an honest error in judgment. Or the person who denied your claim may not have had all of the pertinent information. Have your medical log, with notes on your doctor's recommendations, at your side when you call. Keep notes on each phone call, too: when you called, whom you spoke to, what was said. 7. Put it in writing. If phone calls aren't returned, or don't result in fair treatment, write a letter to the appropriate person (as noted in the plan's appeal procedures). If it's recommended, send a copy to the appropriate state regulatory body (or bodies), and note clearly on the original that the copy (or copies) are being sent. Be sure to include the following information: the procedure your doctor recommends, the reason(s) the procedure is necessary the stated reason for denial the date of the denial, and the reason(s) the procedure should be covered all information required by your plan's procedures, and your state's regulations. If at all possible, get your doctor to include his/her written explanation of why the procedure is necessary and justified. Send the letter overnight, and call to confirm its receipt. Or send it "return receipt requested." Politely insist on a response to your letter in accordance with plan and regulatory deadlines. 8. Get a lawyer if you don't get a clear, fair, timely response to your appeal. When to get a lawyer  There are many difficulties you can handle on your own, with information and determination. However, there are several indications that you may need an attorney when dealing with a doctor, a hospital, an insurer or a managed care plan: 1. Your doctor or hospital commits what you suspect is medical malpractice. 2. The delay or denial of treatment is adversely affecting your health. 3. You're being denied coverage based on policy language that is vague or misleading. 4. Your plan refuses to respond to your written appeals or requests for information within the time frame specified in your policy. 5. Your plan refuses coverage despite a decision in your favor by an external review board, a court or your state insurance commission. If you think you might need a lawyer, find an expert as quickly as possible. Time can make the difference between life and death. In malpractice cases, there are often statutes of limitations. Medical Malpractice  Medical malpractice, by definition, requires negligence (care that falls below the accepted standard of care within the medical area of specialty) on the part of a doctor, hospital or other institution. If this negligence results in injury or wrongful death, malpractice has been committed. What is malpractice?  To put it in simple terms, you have a malpractice case if: 1. you have suffered an injury, and 2. the injury was caused by the mistake. A good lawyer can help you assess if these factors are present, usually in a no-charge consultation. What are your options? If you're the victim of malpractice, your best option is usually to get help from a lawyer. And call immediately. An expert lawyer may offer your only hope of obtaining appropriate compensation, which you may need to pay the bills that result from medical negligence. Also, realize that many states have short statutes of limitations on medical malpractice matters, so that waiting may eliminate your chances of compensation. Your doctor, hospital or insurance plan may try to discourage you from calling a lawyer. Keep in mind: they may be motivated by financial self-interest. So they may try to make you feel guilty, ashamed, or fearful about contacting an attorney. Caps on damages. Unfortunately, many states now have laws that "cap" medical malpractice awards, no matter how badly the patient is injured. These caps vary from state to state, and were usually enacted as the result of "tort reform" campaigns, financed by the medical lobby and the insurance industry. These legal restrictions are often the result of laws supported by the insurance industry, under the guise of "tort reform" or "insurance reform." "Suit-proof" HMOs. As far as medical malpractice goes, it's almost impossible to sue a health plan, except in very rare circumstances. A 1974 federal law called ERISA is widely interpreted to mean that employer-funded health plans can't be sued for malpractice in state courts. However, plans that aren't funded by actual employers (union and government plans, for instance) aren't protected by ERISA. A good patient rights attorney will know if your plan can be held legally accountable for its decisions. Also, recent Congressional legislation should make HMOs less "suit-proof"--if it indeed becomes law. The much-vaunted "Patient Bill of Rights," which addresses this issue, is not yet an actual law as of this writing. Although versions of this bill have been passed by both the House and Senate, its actual provisions are still subject to change before it goes to the White House. Links and addresses  Following are links to grassroots Patient Advocacy organizations, and to your elected officials. Let them know what you think of patient rights issues. The Center for Patient Advocacy is a private, non-profit organization "founded to represent the interests of patients nationwide and dedicated to ensuring that all Americans have timely access to the highest quality medical care in the world." The Health Administration Responsibility Project offers information about health care policy and HMOs. Billed as "the voice for health care consumers," this site is a service of the Families USA Foundation.  -The patient has the right to considerate and respectful care. -The patient has the right to know, by name, the physician responsible for coordinating his or her care at the Clinical Center. -The patient has the right to obtain from his or her physician complete current information about diagnosis, treatment, and prognosis in easily understandable terms. If it is medically inadvisable to give such information to the patients, it will be given to a legally authorized representative. -The patient has the right to receive from his or her physician information necessary to give informed consent prior to the start of any procedure or treatment. Except in emergencies this will include, but not necessarily be limited to, a description of the specific procedure or treatment, any risks involved, and the probable duration of any incapacitation. When there are alternatives to therapeutically designed research protocols, the patient has the right to know about them. The patient also has the right to know the name of the person responsible for directing the procedures or treatment. -The patient has the right to refuse to participate in research, to refuse treatment to the extent permitted by law, and has the right to be informed of the medical consequences of these actions including possible dismissal from the study and discharge from the institution. If discharge would jeopardize the patient's health, he or she has the right to remain under Clinical Center care until discharge or transfer is medically advisable. -The patient has the right to be transferred to another facility when his or her participation in the Clinical Center study is terminated, providing the transfer is medically permissible, the patient has been informed of the needs for and alternatives to such a transfer, and the facility has agreed to accept the patient. -The patient has the right to privacy concerning the medical care program. Case discussion, consultation, examination, and treatment are confidential and will be conducted discreetly. The patient has the right to expect that all communications and records pertaining to care will be treated as confidential to the extent permitted by law. -The patient has the right to routine services whenever hospitalized at the Clinical Center in connection with the active protocol for which he or she is eligible; these services will generally include diagnostic procedures and medical treatment deemed necessary and advisable by the professional staff. Complicating chronic conditions will be noted, reported to the patient, and treated as necessary without the assumption of long-term responsibility for their management. The patient may be returned for long-term or definitive care of these conditions to the referring physician or to other appropriate medical resources. -The patient has the right to expect that medical information about him or her discovered at the Clinical Center, as well as an account of his or her medical program here, will be communicated to the referring physician. -The patient has the right, at any time during the medical program, to designate additional physicians or organizations to receive medical updates. The patient should inform the Outpatient Department staff of these additions. -The patient has the right to know in advance what appointment times and physicians are available and where to go for continuity of care provided by the Clinical Center when such care is required under the study for which the patient was admitted. I hope some of this helps everyone. Just type in Patient Rights into Google and add the state or area which you live in to see more specifics in your area.

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