The methods used to compensate managed care providers can encourage them to provide less, rather than more, care to plan participants. Public disclosure of financial arrangements with doctors as well as information on utilization review standards and decisions, grievance or appeals procedures, and limitations on coverage are of vital importance. Consumer oversight boards, that include health care workers, can be a vital part of protecting patients rights.
Most plans cover only medically necessary services.
Plans will generally refuse to cover experimental treatments. Ask the plan to define these terms. This may be true even if the doctor feels that the more expensive or uncovered treatment is advisable. Ask if the plan has any type of formal or informal gag clause which would prohibit physicians from discussing all possible treatment options, even those that are costly or not covered by the plan. Some states have passed laws prohibiting gag clauses and the federal government prohibits gag clauses in Medicare and Medicaid contracts.