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 Back in 1998, the Patient's Bill of Rights aimed at establishing an office of the Insurance Ombudsman in each state across America. The provisions of that bill were to apply to all health care plans and were important to the offering of valuable health care including access to care, monitoring the quality of care offered, protection of patient information and a process for grievances and appeals.
In this publication we are going to discuss the roles and responsibilities of an insurance ombudsman as well as the types of services they can offer to consumers. We'll finish up with some information on how to find an insurance ombudsman in your area of the country.
Role of Insurance Ombudsman
The role of an ombudsman is to investigate complaints or grievances between parties and mediate fair settlements. In this way they serve as a kind of consumer advocate to make sure that patients are getting the medical care that they are entitled to and deserve under their insurance policies.
Responsibilities of Local Insurance Ombudsman
One of the responsibilities of your local ombudsman is to monitor insurance companies and make sure they are complying with federal and / or state law. This can also include taking a consumer advocacy position with respect to pending policy changes or availability of insurance coverage.
Another responsibility of your local ombudsman is to monitor the insurance landscape - looking for what appear to be emergent patterns of abuse. This includes consumer complaints regarding automobile insurance claims or settlements, insurance credit scoring, homeowner insurance cancellations or non-renewals, claim and underwriting practices of insurers, as well as health insurance issues.
It is because of these roles and responsibilities that insurance ombudsman can often lend a hand when it comes to consumer protection issues.
Insurance Companies that Refuse to Pay
Many times patients find themselves referred to doctors that perform special surgeries or have insights into a process that is particularly effective in the situation they are faced with. But with the growing popularity of managed health care programs such as health maintenance organizations or HMOs, patients are often frustrated when these referrals point to doctors that are out of network.
Many patients choose to pay for the costs of these procedures out of their own pockets when insurance companies refuse to pay. For some families, this financial burden adds to the stress and worry that comes when a loved one is suffering with an illness. This is where the office of an insurance ombudsman can lend families a helping hand.
Ombudsman and Insurance Appeals
An insurance ombudsman is accustomed to looking through insurance policies and figuring out whether or not the patient is truly entitled to the care they need. By law, all insurance companies offering insurance policies are required to provide patients with an appeals process. Unfortunately, this information is usually buried deep in the policy documentation and written in a manner that usually requires an attorney to interpret the legal jargon.
In fact, the ombudsman can help you to avoid a long and costly legal battle with your insurance company by walking you through these appeals processes. The entire process may take time and may require families to gather some additional documentation, but in many cases the appeal results in a positive outcome for the patient.
That's because insurance companies have established an appeals process to make sure consumers are protected. Unfortunately, families are often too worried to about their loved ones and they really don't care about or even want to think about going through a process - They just want the proper medical care to be administered.
Finding Insurance Ombudsman
The government thought that the best way to assure consumer protection was through an office of the insurance ombudsman in each state. Unfortunately for the consumer, the name of the office can take many different forms - Health Care Ombudsman, Insurance Ombudsman, Office of Consumer Advocacy just to name a few.
To make matters worse, the ombudsman office may be split or specialize in certain types of insurance - for example, Medicare versus privately held insurance. This is where the Health Assistance Partnership can help out.
Funded by the Robert Wood Johnson foundation, the Health Assistance Partnership was established to meet the needs of America's health insurance consumers. This Partnership maintains a comprehensive list or directory of ombudsman programs throughout the US. To find a specific program online, just go to the program locator section of their website.
About the Author - Insurance Ombudsman
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