In a world where health care is complex, expensive and a sometimes a lot inaccessible, we all face some or the other problems with our health insurance providers. If not approached properly or systematically, some errors on your part and/or the insurance company’s part can land you in serious health issues or even denied treatment. Health Maintenance Organization or HMO plans are no different.

Following are a few tips that can help you in dealing with your HMO.

• When you choose your provider, the first step many of the HMO’s ask you to do is choose a primary care physician. While making that choice, you should be careful and choose a physician that you like or will get along with. If you just chose the name off a list or your HMO assigned a doctor to you, see if you get along with him/her in your first few visits. If you don’t, talk to someone at your HMO for a change.
• Since you are a paying customer of the HMO, you have certain rights too; be aware of them. If your HMO denies a request for treatment, you may want to investigate, especially the appeals process. Every company has specified process that you need to follow. At the same time, if they do not entertain your valid claim, you can approach your state’s insurance commissioner.
• If you need to see a specialist for some need or procedure, discuss such need with your primary care physician first. Usually, most HMOs require your primary care physician to approve such appointments with specialists.
• In some cases, second opinions are important and in many cases, your HMO will pay for them. In case it doesn’t, ask your HMO for an explanation and to put it in writing as well.
• In case of denied HMO claims, keep a track of every communication (including the person’s name) that you have with the company. Also make sure that you are dealing with a case manager that has a medical background; most companies have case managers that do not have one.
• You may have a problem in appealing on the issue if your HMO calls a procedure ‘cosmetic’. In this scenario too, make sure that you are talking to a person with a medical background and to add to your efforts, have your primary care provider write a letter to them on your behalf stating the benefits of the procedure. Be clear on how the procedure will improve your bodily function and is not adding to your self esteem.
• If your HMO deems a procedure as ‘dental’ (which are not, but are necessary – example, cleft palate), in this case too, seek letters from your primary care physician, the team and surgeon stressing the medical need of the procedure. Note that in this scenario, getting a letter from your dentist may not be a helpful choice. Demonstrate to your HMO the need to have this procedure in order to minimize latter ones, hence saving the company expenditures on those.
• If your HMO does not allow you to see a team for certain illnesses or procedures, demonstrate and emphasize on how seeking team care can actually lower the cost of procedure.

In addition to this, if your grievances are not addressed, you can first approach the human resources department of your employer. If even that fails in passing your valid claim, you can always approach your state’s insurance commissioner or other such authorities. Also, if you feel that you have a strong case and are not being heard, you can consult with a lawyer for denied HMO claims.