While most people would rather chew on tinfoil than hassle their HMO over a rejected medical claim, those souls brave enough to try now can get some much-needed help. This month, the Kaiser Family Foundation and Consumers Union published a revamped step-by-step guide to resolving disputes with health plans. The site includes information about understanding what type of coverage you have, how to resolve disputes within the framework of your health plan, and where to go for outside help when negotiations with your health plan fail.

Twenty-nine percent of HMO customers and 23 percent of customers of PPOs (preferred provider organizations, another major type of health plan) say their families don't get the medical care they need, according to a survey by Consumers Union. But when health plans deny care or payment, patients do have rights under federal and state law.

To prepare yourself to dispute a rejected medical claim, the first thing to do is know your health plan.

"When you or some family member is sick, it's really not the time to try and understand your coverage," says Janet Lundy, a senior program officer with the Kaiser Family Foundation. "You need to try to understand it ahead of time."

Some group health plans, for instance, don't cover infertility, obesity, cosmetic, and acupuncture treatments, while many individual plans don't cover pregnancy, substance abuse, mental illness, and nursing homes. Further, health plans often require referrals to specialists and pre-authorization for certain types of surgery. Also, beware of appeal deadlines; most plans stipulate that patients must file an internal review appeal within 30 days. The KFF site provides a simple worksheet that can help answer questions about the extent of your coverage. Knowing this information can help prevent some health plan problems before they occur.

If you think you do have a legitimate complaint—perhaps your plan denied a treatment that you and your doctor feel is necessary—start documenting your case immediately. Collect bills, test results, and explanation of benefits statements, and write down the names of whom you talk to and what you talk about.

"When you have all your information, it helps you stand your ground with the health plan," says Lundy. "Sometimes the people at the other end of the telephone don't understand the benefits very well."

It might also behoove the patients to accumulate scientific data to back their claims, such as medical journal articles or treatment guidelines; many disputed claims involve experimental treatments, often involving cancer or obesity patients.

When negotiations fail

When negotiations with a health plan fail, patients can look to outside sources of help. Where people should look for this help depends on the type of insurance. Medicare and Medicaid each have their own review processes that provide assistance to settle disputes. Companies with self-funded plans, where the company assumes financial responsibility for the healthcare costs of its employees, fall under the Employee Retirement Income Security Act (ERISA), which provides federal guidelines for these companies to follow in disputes. Beyond these guidelines, dissatisfied patients can try resolving their dispute through the Department of Labor or can file a lawsuit. Finally, people who buy individual insurance and employers who buy insurance from an outside company come under the review of the states, some of which have an external review process. (Employers who buy insurance also fall under the ERISA laws.)

Forty-three states and Washington, D.C., provide patients with an external review. An independent group will look at denied healthcare claims after the patients have exhausted all the options within their health plan. Some states also require health plans to pay for certain treatments, especially with conditions like diabetes and heart disease. Another website, statehealthfacts.org, can help people figure out which states mandate treatments for certain ailments.

The KFF and Consumers Union site contains a state-by-state section on external reviews, complete with links to the state agencies responsible for reviews and oversight. Following each state's guidelines is essential, especially providing the necessary documentation and completing the internal review process first. A large percentage of people who file for an external review get turned down simply because they don't know the rules, according to Consumers Union.

"We found, in our survey, that people are turned down at the external phase," said Trudy Lieberman, director of the center for consumer health choices at Consumers Union. "Consumers don't understand the process; they don't understand that they have to go through the internal review first."

There are rewards for providing the proper documentation and following all the rules: Health plans often surrender at the beginning of the external review. Even if they don't, patients still win their external reviews roughly 50 percent of the time, depending on the state. (For instance, patients got compensation 21 percent of the time in Arizona and Minnesota, compared with 72 percent in Connecticut during the late 1990s and 2000.)

"It's not easy to pursue these appeals," says Lundy. "It takes time, it takes persistence, and it takes a little work. They [patients] shouldn't give up."