Insurance Advocacy

Tips for Medical Insurance Advocacy.

Here are six important tips about the critical things to do when you deal with your private medical insurance company:

1. Gather, read and understand the medical insurance benefit plan book. The book may be called by one of many names–possibly the Summary Plan, the Evidence of Coverage, the Summary of Benefits. This booklet describes your coverage in detail.

2. Organize the paperwork in a way that makes it simple for you to keep track of what has been covered in the past, the important definitions within the benefit plan book for you, and the criteria used for each benefits you need. It is important to create a system that works for you.

3. Write everything down for each item, therapy, or doctor’s visit you want covered, including everyone with whom you have spoken and what was said. Again, organization is extremely important and a detailed phone log, correspondence, insurance documents, and medical information should be kept with the information on the insurance coverage for easy access. If it seems too hard for you, remember that the insurance company records every call with you, including the substance of the call! If there is a dispute later, you must have at least as much information about the sequence and substance of the calls as they do.

4. Start by asking questions. It is much more effective to start by asking questions, rather than starting out with an emotional response or stance. It is best to remain calm and positive. Several initial questions to ask include how to read the benefits information, how to obtain the criteria for the medical equipment, or what the definition of medical necessity means in a given instance.

5. Be prepared, firm and focused with a particular request of what you want from the insurance company. Remember that the claims person probably speaks to 50 or more people per day, and most of those calls are from unhappy or angry patients and caregivers. If the claims person doesn’t have the information you need, kindly ask for a supervisor. Do not be deterred from getting the answers you seek.

6. Involve your doctor. Make sure your doctor is in support of the medical care you are seeking and believes it is medically necessary.


Health Insurance Advocacy Program Locator
Provides refrrals to health insurance assistance programs which can answer questions about health insurance and/or health insurance benefits. Programs may also be able to refer you to low-cost or free health care, including prescription drug assistance.