Consumer Publications List
Facing what he
considered to be a health care emergency, a Maryland consumer placed his
daughter into in-patient drug treatment in another state. The facility had been
recommended by a Maryland social worker who specialized in treating drug
addictions. However, the consumer's insurer did not authorize the treatment and
the facility was not part of the plan's network. The bill totaled $17,000 and
the insurance company refused to pay, leaving the consumer responsible for the
Consumer Protection Division's Health Education and Advocacy Unit receives many
complaints each year from people who have received unexpected charges following
a medical procedure. As insurance becomes more complicated and more and more
health care providers participate in managed care plans, it is crucial that
consumers know how their health insurance or HMO works and follow the procedures
for receiving covered care. You will need to take care of all of these details
before your medical procedure so you won't end up with bills your insurer won't
pay afterward. Here are some points to remember:
you have any kind of elective medical procedure or surgery, you should seek a
second opinion. This is sound medical advice and is actually required by some
types of insurance plans. Even if your plan does not require a second opinion,
it will usually pay for it. You may have to use a doctor within your chosen
group or plan. Check with your insurer to find out how this works in your
consumers contact their insurer to ask if a procedure is covered and are told it
is covered by their benefits package. Later, they are surprised when the insurer
refuses to pay their bill. Although an insurance plan may provide coverage for a
particular kind of procedure, you may still need to receive authorization or
meet certain conditions to have the insurer pay a claim for that service.
You need answers to two questions to determine if your health plan will pay
for a medical procedure:
the treatment covered by the plan? If so,2. Does your condition meet the
plan's criteria to qualify for treatment?
factors might complicate things:
Pre-existing condition limitations:
If you had the condition for which you need treatment prior to joining the
insurance plan, your insurer may not pay for the procedure.
preauthorization: If your doctors did not receive authorization to perform the
procedure on you, it might not be covered even if you otherwise meet all of the
qualifications for coverage.
network limitations: Although your insurance plan may cover a certain procedure,
your access to a particular physician or facility to perform that procedure may
be limited by the medical group you choose within your plan.
Establishing medical necessity:
Most plans require certain criteria be met to establish medical necessity for a
procedure. If your doctor does not demonstrate that your condition meets the
criteria to establish medical necessity, the procedure may not be covered by
with the doctor who is to perform the procedure as well as your primary care
doctor to be sure you receive proper authorization, and that the authorization
covers all recommended treatment including follow-up care.
need to check the status of each person involved in your treatment to be sure
they participate in your insurance plan. Some other providers who may be
involved include pathologists, radiologists, anesthesiologists, laboratories and
assistant surgeons. Even if you are having surgery in a participating hospital
with a participating surgeon, it is possible the anesthesiologist or radiologist
may not participate in your plan.
the physician performing the procedure to determine who will be involved. Your
insurer can help you determine who among them participates and whether the
facility (hospital, outpatient surgical center) participates.
cases you will have a choice of providers and facilities. If your surgeon works
at several hospitals, you can choose the one that participates with your
insurance plan. The same may be true of other providers involved in your care.
However, in some cases you may not have a choice. If you must deal with someone
who does not participate in your plan, talk to your insurer. Some plans may
agree to pay the difference in cost if you have no other options. Or the
provider might agree to accept your plan's usual and customary payment.
Depending upon the type of insurance you have, if a provider does not
participate in your plan and won't accept assignment, you might be billed for
the difference between what your plan will pay and the provider's charge for the
the procedure, talk to your physician about what follow-up care you will need.
If you will need physical therapy, for example, find out how many visits will be
approved, under what conditions is coverage granted and who are the
participating therapists in your area.
are covered under two different health insurance policies - your own and your
spouse's - you need to address all of these issues with both insurance
companies. Each plan may require different criteria and different
authorizations. Coordinate your primary and secondary coverage before the
procedure to be sure your bills will be paid afterward.
Maryland Attorney General's Consumer Protection
DivisionConsumer hotline: (410) 528-8662 or 1 (888) 743-0023 toll-free
200 St. Paul Place, Baltimore, MD 21202
410-576-6300 / En español 410-230-1712 / 1-888-743-0023 toll-free / TTY: Dial 7-1-1 or 800-735-2258