How Can the Health Care Section Help Me?

Many times the biggest frustration in dealing with health insurance agencies and HMOs is not knowing where to turn when you have a complaint. Here are some situations in which the Attorney General’s Health Care Section may be able to help.

My son is seven years old and has severe asthma. Although it seems we are in our primary care physician’s office constantly, our child is not getting any better. We heard about several different treatments that would better manage his asthma, but our doctor says the HMO won’t cover any of his disease management or medications. Can you help us?

Yes.  This case represents an “access to care” issue.  File a complaint with the Health Care Section, and we’ll help to make sure the HMO provides the “access to care” to which your child is entitled.

I had surgery at a local hospital. When I checked the bill over, I knew there were charges for medications and post-operative therapy I never received. I’ve already paid, but I just know that my insurance company and I are unfairly paying for those charges. What can I do?

This is a billing dispute, and the Health Care Section can investigate and mediate your dispute. If the hospital (or any health care provider) insists the charges are valid or ignores your concerns, file a complaint with the Health Care Section. We can also help resolve other billing disputes.

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I have several health problems, and in order to treat one without making the others worse, my physician started me on a certain course of treatment. When the doctor’s office filed the insurance claim, the company refused to pay because it said the treatment was not medically appropriate. But my doctor says it is. What can I do?

File a complaint with the Health Care Section. We can help with insurance coverage disputes, including situations when the insurer denies services your doctor says you need, won’t pay claims, or puts up barriers to your getting the care you need.

My doctor referred me for an MRI, but the insurance company says it’s an expensive test that isn’t necessary. My doctor believes it’s the best way to find out exactly what’s causing my problem. How can my insurer say no and what can I do about it?

Your question falls in the area known as “underutilization of services.” In other words, your health plan is not allowing you to make full use of medical services. The Health Care Section may be able to help you secure treatment if you file a complaint.

I haven’t had any problems with my health care plan before, but when I went to pick up a prescription at the pharmacy, the pharmacist said the prescription benefit manager my plan uses refused to cover this medication. When I asked why, he said the company has dropped several prescriptions from their coverage list, including mine. Can you help me?

Yes. The Health Care Section will handle prescription coverage and payment issues. Just file a complaint form.

I purchased health insurance because I can’t get it through work. But I haven’t found a doctor anywhere who is a member of the plan, and I can’t get a straight answer from anyone at the insurance company. Help!

This could be a violation of the Consumer Protection Law.  By filing a complaint, you’ll be letting the Attorney General know that there’s a company that’s taking Pennsylvanians’ money without making good on its promises.  We’ll attempt to help you and others get satisfaction and potentially stop this company from doing business here in the future.

My mental health therapist says that my insurance company is asking for excessive paperwork to demonstrate my therapy is medically necessary, and my insurance company limits how many times I can see my provider.

If your insurance company imposes more barriers to accessing mental health care (or substance use disorder treatment) than it does for your physical health, this could be a “parity issue.” File a complaint with the Health Care Section, and we can try to make sure you have access to all the care to which you are entitled.

I need inpatient treatment for substance use disorder, but I cannot find anyone in network to provide that treatment. My insurance company will only cover a much shorter stay than my doctor recommends.

This could be a “parity issue” if your insurance company is making it harder for you to access inpatient treatment for your substance use disorder than it would for any inpatient surgery you may need. The Health Care Section may be able to help you if you file a complaint with our office.