What is the Plan's Reputation?

This is a tough one. Almost all plans make doctors sign contracts prohibiting them from saying bad things about the company.

Even in states that prohibit "gag clauses," the details of how a plan manages care may be considered "proprietary:" trade secrets that they have a right to conceal from competitor plans.

However, that doesn't prohibit anyone from saying good things about other health plans, so your most productive tactic may be to ask around about what the best plans are, not whether a particular plan is bad or good.

You can also ask factual questions about the general details of the cost management strategies I described:

What kinds of procedures or prescriptions need pre-authorization?

Which services are capitated, and to whom?

Does the plan use any at-risk arrangements that could affect you?

Which rehabilitation hospitals can you use?

How is mental health care provided?

How have the plan's policies changed in recent years (and are changes usually announced in January and July, after open enrollment is closed)?

Call your doctor with the names of the companies offered and ask which he prefers (and maybe why). Your doctor's office manager or billing service may be able to tell you which companies pay most promptly and which will be the quickest to answer the phone to confirm your benefits when you arrive for an appointment. Your hospital's utilization management department can tell you which plans are most reasonable at approving inpatient care. Your pharmacist will probably have a few choice words about the prescription benefits of some plans. A doctor who no longer takes a plan may be at more liberty to tell you the down-and-dirty of why he stopped.

If you are calling on behalf of a group of employees at your company, you will likely find people willing to spend more time talking to you -- they won't feel like they are opening the door to a whole lot of calls from people who all want to ask about their health plan.

Another useful indicator is how long the plan has been operating under its current name. Insurers spend millions of dollars for advertising to make sure you recognize their names at open enrollment time. If a plan has a good reputation, it will be very loathe to change its name. Even if it is necessary due to a merger of two equally reputable companies, the new company goes to a lot of expense to advertise the new name. A plan that changes its name -- without making sure everyone knows it is still the same company -- may be trying to shed a negative public image.



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©2000 Eileen K. Carpenter, MD