1601 N. Tucson Blvd. Suite 9
Tucson, AZ 85716-3450
Phone: (800) 635-1196
Hotline: (800) 419-4777
Association fo American Physicians and Surgeons, Inc.
A Voice for Private Physicians Since 1943
Omnia pro aegroto

For Patient Power:

The Patient's Handbook
Jane M. Orient, M.D. and Kathryn Serkes

Association of American Physicians and Surgeons, Inc.

1601 N. Tucson Blvd. Suite 9
Tucson, AZ 85716?
(800) 635-1196


INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . .1

YOUR RIGHTS AS A PATIENT . . . . . . . . . . . . . . . . .2

Patients' Bill of Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
Your Medical Record and Your Right to Privacy. . . . . . . . . . . . . . . . . . . . . . . . . . . .2
Checking Your Medical Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

WHAT CAN YOU EXPECT FROM YOUR DOCTOR?. . . . . . . . . . . . . . . . . . .3

Availability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Communication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Notice of Fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
Access to Medical Records. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
Guarantees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

WHEN SHOULD I CALL THE DOCTOR?. . . . . . . . . . . . . . . . . 4

In an Emergency, Dial 911. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
When to Go to the Emergency Room . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
What If You Are Sick on a Weekend, at Night or on a Holiday? . . . . . . . . . . . . . . . . . . . .5


Phone Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Before The Office Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Questions to Ask Your Doctor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

FEES . . . . . . . . . . . . . . . . . . . . . . . . . . .7

WHEN DO I NEED A SPECIALIST? . . . . . . . . . . . . . .8

PRESCRIPTIONS. . . . . . . . . . . . . . . . . . .8

Saving Money on Prescriptions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Cracking the Prescription Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

CHOOSING HEALTH INSURANCE. . . . . . . . . . . . . . . . . . . . . . . . .9

Insurance vs. Health Care Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Health Maintenance Organizations (HMOs). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

TEN QUESTIONS TO ASK AN HMO. . . . . . . . . . . . . . . . . . . . 11

Medical Savings Accounts (MSAs). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

WHEN YOUR INSURANCE CLAIM IS DENIED. . . . . . . . . . . . . . . 12

YOUR RIGHTS UNDER MEDICARE . . . . . . . . . . . . . . . . . . . . 13

Your Rights Are Restricted . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Private Contracting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Medicare HMOs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Medigap Insurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

TESTING . . . . . . . . . . . . . . . . . . . . . . . . . 14

HOSPITALIZATION. . . . . . . . . . . . . . . . . . . . . . 14

Keeping Track of Your Hospital Bill. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

PREVENTIVE MEDICINE. . . . . . . . . . . . . . . . . . . . . . 15

YOUR PERSONAL MEDICAL RECORD . . . . . . . . . .16

GETTING MORE INFORMATION . . . . . . . . . . . . . . . . . .18

Tape Libraries.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Self-help and support organizations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

For Patient Power:

The Patient's Handbook

by Jane Orient, M.D., and Kathryn Serkes


The Association of American Physicians and Surgeons, Inc, is a non- partisan organization dedicated to the sanctity of the patient-physician relationship. Since 1943, AAPS has worked for patients' rights and excellence in medicine.

For more than 50 years, AAPS has operated on the principle that physicians are partners in the care of their patients. If your doctor is a member of AAPS, that means he embraces the Oath of Hippocrates and believes that his duty to the patient comes first. He works for the good of the patient, not that of the government, an insurance company, or a managed health care bureaucrat.

The most frequent complaint about the medical profession is a lack of communication and respect for patients. The maze of medical care can be confusing. When faced with difficult medical decisions, it sometimes seems that your doctor speaks another language, and no one has given you the translation. AAPS has written this handbook to tackle that problem -- to increase communication and convey the highest respect for the dignity of the patient. While a booklet this size can't answer everything, we have addressed the most frequently asked questions we hear from our patients.

We urge you to use this handbook. Take it with you to the doctor to ask questions. Make notes in it. The more you communicate with your doctor, the better he will be able to act as your advocate.

YOU are the most important partner in your medical care.


Insist on your rights as a patient!

If your doctor gave you a copy of this handbook, he is probably a member of AAPS and has agreed to the Bill of Rights. If not, show it to your doctor and ask him to sign and return to AAPS. If he won't agree to your basic rights, you might want to think about finding another doctor.


All patients should be guaranteed the following freedoms:
  • To seek consultation with the physician(s) of their choice;
  • To contract with their physician(s) on mutually agreeable terms;
  • To be treated confidentially, with access to their records limited to those involved in their care or designated by the patient;
  • To use their own resources to purchase the care of their choice;
  • To refuse medical treatment even if it is recommended by their physician(s);
  • To be informed about their medical condition, the risks and benefits of treatment and appropriate alternatives;
  • To refuse third-party interference in their medical care, and to be confident that their actions in seeking or declining medical care will not result in third-party-imposed penalties for patients or physicians;
  • To receive full disclosure of their insurance plan in plain language, including:
    1. CONTRACTS: A copy of the contract between the physician and health care plan, and between the patient or employer and the plan;
    2. INCENTIVES: Whether participating physicians are offered financial incentives to reduce treatment or ration care;
    3. COST: The full cost of the plan, including copayments, coinsurance, and deductibles;
    4. COVERAGE: Benefits covered and excluded, including availability and location of 24-hour emergency care;
    5. QUALIFICATIONS: A roster and qualifications of participating physicians;
    6. APPROVAL PROCEDURES: Authorization procedures for services, whether doctors need approval of a committee or any other individual, and who decides what is medically necessary;
    7. REFERRALS: Procedures for consulting a specialist, and who must authorize the referral;
    8. APPEALS: Grievance procedures for claim or treatment denials;
    9. GAG RULE: Whether physicians are subject to a gag rule, preventing criticism of the plan.

Your Medical Record and Your Right to Privacy

Few areas are more personal and private than your medical records. Yet there are more safeguards for financial records than for health information. With the proliferation of huge medical networks and computerized

information, the potential for someone to gain access to and misuse your records is tremendous. In 1994, 11 state workers in Maryland tapped into a Medicaid database and sold medical information to HMO recruiters.

The Supreme Court has recognized a ``right to privacy'' by patients. But some insurers and health care plans aren't disposed to protect your right. In fact, they frequently coerce you into signing blanket disclosure forms.

If you wish to withhold consent to disseminate your medical records, sign this form and give it to your physician.

I, ___________________________, hereby assert my constitutional right to privacy and expressly forbid my physician, and anyone acting under his or her control, from releasing any of my medical records to a third party without my express consent.

In particular, I decline to consent to the release of my medical records for the purpose of entry into a computer database which may be accessed by third parties outside of the offices of hospitals utilized by my physician.

___________________________________________ Signature Date

Checking Your Medical Record

While most Americans assume they have access to their medical records, as of this writing only 28 states protect this access. Even if you make copies of your doctor's files, how do you know your insurance company records aren't full of inaccuracies which could haunt you for life, resulting in denial of coverage or harassment?

If your insurance company won't provide you with your records, there is another option. The Medical Information Bureau is an association of insurance companies which keeps computerized files, much like a credit bureau. If your insurer is a member, you can check your file for errors. Contact: Medical Information Bureau, P.O. Box 105 Essex Station, Boston, MA 02112, (617)426-3660.


The patient-physician relationship should be built on a foundation of communication and respect. These are the basics:


Your physician should keep reasonable office hours and be available by phone. He should schedule adequate time for an office visit to make a diagnosis and answer questions. But remember, even with careful scheduling, appointments can back up, and you may have to wait. Once a patient is in the examination room, it may take longer than expected if the diagnosis is more complicated than could be foreseen. Please be patient -- you expect the doctor to take the same care and diligence when it's your turn.


Your doctor should welcome your questions -- they help him make a correct diagnosis. The more you prepare yourself, using the guides in this handbook, the more effectively you can communicate.

Notice of Fees

Your doctor should be willing to tell you fees in advance and give notice of increases. But some fees are like estimates -- you may need more care than expected or a procedure may be more difficult than could be reasonably predicted. It is reasonable for the doctor to let you know as soon as he discovers the fee is likely to exceed the estimate.

Access to Medical Records

While the physical medical records belong to the physician's office, you have a right to access and make copies of your medical information. Under special circumstances, a physician may want to withhold a portion of the record that he deems harmful to a patient at a certain stage of treatment, but he should be ready to explain why.


There is one thing your physician cannot give -- a guaranteed result. Since people invented automobiles, it is fair to expect them to give warranties. But nobody is smart enough to design a human body, and spare parts are unavailable. All medical decisions are based on probability. Despite tremendous developments, our understanding of the body is still limited, and many diseases and problems are beyond our power to cure.

The only guarantee your physician can make is that he will treat you with respect, and use the full extent of his training and wisdom in providing your care.


Most physicians keep regular office hours during weekdays, and more are offering evening or weekend time to accommodate working families. Check with your physician for his hours and jot them down:

Phone #

Unfortunately, your body doesn't always adhere to your doctor's schedule, and medical problems erupt at night, on weekends, or on holidays. Most medical offices have 24-hour answering services to handle your calls, but it pays to be prepared in advance. Ask your physician about after-hours procedures.

In an Emergency, Dial 911

If you are sure something is an emergency, don't delay. Call the paramedics. They are awake, dressed, equipped, and on the radio. Situations that need the paramedics include:

  1. Unconsciousness lasting more than a few moments;
  2. Shock (patient looks pale and clammy, has a weak, rapid pulse, and can't stand up without feeling faint);
  3. Sudden or severe difficulty breathing;
  4. Severe, crushing chest pain, especially with a cold sweat or nausea or sense of impending doom.
  5. An injury with severe bleeding;
  6. If you are alone, an injury or fracture which would prevent you from getting to the hospital on your own.

When to Go to the Emergency Room

Some problems call for an immediate trip to the emergency room, but not necessarily by ambulance. (Use your common sense about what type of transportation is safe.) Some examples are:

  1. Bleeding from the stomach or intestines, other than in small amounts. (Blood that has remained in the stomach for a time may appear as vomitus resembling coffee grounds or as black, tarry, foul-smelling stools);
  2. Sudden, severe headache;
  3. High fever if accompanied by a stiff neck or delirium.

Situations that probably warrant admission to the hospital, but which can possibly be evaluated in the office first, include:

  1. Vomiting in a diabetic;
  2. High fever with shaking chills, especially if the patient can't keep down fluids or medicines.

What If You Are Sick on a Weekend, at Night or on a Holiday?

Some problems can be handled on the telephone, or can wait until morning or Monday. Others may require a visit to the office or emergency room, but either will cost more than a regular visit. A special trip to the office requires much more time than the usual office visit, and the fee is proportionally higher.

Only you can decide if a trip to the emergency room is necessary. But remember, they're designed to save lives. Care for problems that aren't too urgent (in their judgment, not yours!) may be slow, inefficient, and expensive.

Take two aspirin and call your doctor in the morning? Often, that is not bad advice. People recover from most illness without or in spite of modern medicine. Otherwise, the human race would have been extinct long ago! A delay of a few hours in starting most medicines makes no difference. If the problem is pain, a few hours may seem like days. If you know the cause of the pain (toothache, earache, sprained ankle) then take some medicine and call in the morning. If you don't know that you have a minor problem, it is better to be seen than to be sorry.

Should you start taking an antibiotic? Generally NO, NO, NO! If you are developing a serious illness, it is important to obtain cultures to identify the bacteria and select the appropriate antibiotics. A couple of leftover tablets of tetracycline may ruin the culture.

Your doctor may suggest some exceptions to the rule, for example a bladder infection. If you are developing familiar symptoms, he might want you to start an antibiotic if you are sure you don't have VD (burning on urination is one symptom) and you are not having fever and chills. Ask about obtaining a specimen before you start taking the medicine.


Nearly 95% of diagnosis is the history. The quality of the advice you get from your physician depends on the quality and amount of information he obtains from you. Be prepared.

Phone Consultation

When you come to the office, you don't like to be interrupted or kept waiting while the doctor takes routine phone calls. Others expect the same courtesy. Instead of asking to speak to the doctor, tell the receptionist the reason for your call. She may be able to help you at once or to identify the need for the doctor's urgent attention. Otherwise, your doctor will call you back when it is convenient.

Be ready to describe your symptoms. Having the flu, feeling feverish, or being dizzy mean something different to everyone. Take a few minutes to organize your thoughts with the PQRST of your symptoms:

P. Parts involved: ``I hurt all over'' or ``my stomach hurts'' doesn't tell your doctor much. Instead, ``I have a pain in my right upper abdomen that goes into my right shoulder'' is helpful.
Q. Quality of the symptom: Is it a sharp pain? A dull ache? A burning sensation? Does it throb?
R. Relieving and worsening factors: Does eating make it better? Does walking make it worse? Did an antacid help or not?
S. Severity and associated symptoms: Is the pain so bad you have to stop what you're doing and lie down? Do you have nausea, shortness of breath, sweating, blurred vision, or other symptoms as well?
T. Time Course: How long have you had it? Is it getting better or worse? Have you had it before? Has the location changed since it first started? What were you doing when you first noticed it? Does it come and go, or is it constant?

Before The Office Visit

To maximize the time with your physician, here are some things you can do in advance of your visit:

  1. Define your goals. What do you want from the doctor? A complete check up? A consultation on a specific problem? Tell the receptionist so she can schedule appropriately.
  2. Organize your symptoms (See ``PQRST'' above) and make a list of questions.
  3. Get your medical records from previous physicians. Be familiar with your family history.
  4. Make a list of medications you're taking, including prescription and over-the-counter drugs. Know the dosages.

Questions to Ask Your Doctor

Use this list as a guideline when you see your doctor:
Diagnosis. What's wrong, what causes it, and how serious is it?
Tests: What tests do you recommend, and what is the purpose? (See section on Testing, p. 14.)
Results: How will I find out about the results? Will I be advised if nothing is wrong, or only if something needs attention?
Options: What treatment choices do I have?
Medications: What are my choices? What are the side effects, and how will it interact with other prescriptions or over-the-counter drugs? What's the dosage and frequency? Should I take with or without food, or avoid alcohol? (See ``Prescriptions,'' page 8.)
Doctor's Orders: What activities do I need to avoid? Am I contagious? Do I need a follow up visit? Should I watch for anything special?
My Questions: (Jot down things you want to discuss so you don't forget them, but try not to overwhelm the doctor with a ``laundry list.'')


Fees charged depend upon the difficulty of the problem, the amount of time required, and the expense of the supplies and equipment used. Remember, a large part of the fees you pay go toward the doctor's overhead, such as staff, office expense, supplies, insurance, and taxes. And unfortunately, reduced fees under government-controlled programs such as Medicare and Medicaid tend to shift the costs to private patients.

Most offices expect payment at the time of the visit unless you make special arrangements. Some offices will file your insurance claim for you. Others believe, on principle, that you should be in charge of that detail, but will give you needed assistance. Ask in advance.

If you have a question about how much the charges will be, ask the receptionist ahead of time. If the fee seems high or is more than you can afford, don't be afraid to negotiate or ask for special arrangements. Most doctors are sensitive to the issue of cost and don't want it to interfere with their ability to give you the best care they can.


A specialist is a doctor with two or more years of additional specialty training called a residency. Many take more years of training called a fellowship in a specific area of their specialty. After taking the extra training, many doctors will become board-certified by passing a rigorous examination administered by a national board of professionals in that specialty field. They are designated as Diplomates. Most board-certified doctors become Fellows of their medical specialty societies after meeting the full requirements of that society. For example, FACS after a doctor's name means he is a Fellow of the American College of Surgeons.

Because of their additional training and expertise, fees for specialists are usually higher than a general practitioner.

You are most likely to see a specialist when your primary care physician wants to confirm a diagnosis or get a second opinion. In most cases, it is unwise to self-refer to a specialist as the visit may be unnecessary. On the other hand, the right to self referral is something you want to preserve.


More than 60% of office visits result in a prescription. Use of the proper medication in appropriate dosage and manner can not only save your life, but money as well.

Physicians and pharmacists can make mistakes, so don't be afraid to ask questions. Ultimately, it's up to you to take the prescription properly. If you think of questions after leaving your doctor's office, your pharmacist may be able to help. Be sure that you understand:

  • The name of the drug and its purpose. Is it an antibiotic? An antidepressant? Is written information available?
  • Side effects and interaction with other drugs. Is it okay to drink alcohol? Should it be taken with or without food? Most drugstores keep records of drugs they dispense for each customer, and should be able to scan your records for interactions.

Saving Money on Prescriptions

  • Shop around for prices. There is a wide variance from store to store.
  • Watch for sales on prescriptions you take regularly. Drugstores will sometimes put commonly prescribed drugs on sale.
  • Ask about generics. While generics can save money, a word of caution is in order: In some cases, one particular brand name drug is more effective than the generic substitute. Be aware that the pharmacy may actually make more money on generics. Your doctor should always have the final say.
  • Store drugs properly. Drugs need to be kept fresh in a cool, dry climate. Make sure those expensive drugs retain their effectiveness. Certain drugs need special care and can lose potency even before the expiration date; for example, if nitroglycerin doesn't make your tongue tingle, you need a fresh bottle.
  • The main problem with outdated drugs is loss of potency, but a few, such as tetracycline, may form toxic products. Clear solutions, as the adrenalin in insect-sting kits, must be replaced if they become discolored.

Cracking the Prescription Code

The following are the most commonly used abbreviations:

Rx - take
ac - before meals
pc - after meals
qh - every hour
bid - twice a day
tid - three times a day
qid - four times a day
disp #50 - pharmacist should dispense
50 pills hs - at bedtime
po - by mouth
Sig - label, directions
prn - as needed


Health insurers spend millions of dollars on advertising to convince you to buy their plans. But glitzy ads with warm and fuzzy images don't tell the real story of what they will actually cover or cost. And besides, do you want your money spent on your medical care or on ads?

It's tough to find out exactly what health insurance or plans cover. But if you do your homework and become an educated consumer, you will not only save money, but protect your family.

As with any consumer decision, shop around and compare policies. Price may not be the only factor. A low premium may be attractive, but if you can't get the services you need, it's not a good deal. Get schedules of benefits for several policies and compare. Be sure to find out what's not covered as well. Don't be shy about aggressively insisting on answers to the questions.

Insurance vs. Health Care Plans

There is a difference between true insurance and a health care plan, even though the terms are frequently used interchangeably. The best way to understand medical insurance is to think of your auto insurance. You pay a premium for coverage with a deductible. If your car sustains major damage, you pay the deductible portion of the repair bill, and the insurer pays the rest. You don't expect your insurance company to pay for routine maintenance and minor damage, such as oil changes or replacing wiper blades, nor would you expect or want the insurance company to actually make the repairs.

In contrast, health care plans act as both the insurance company and the mechanic. Also called managed care, these prepaid plans combine medical insurance with a medical delivery system. They provide both the coverage and the care. (There is an ``alphabet soup'' of different types, of which HMOs are generally the most restrictive.) Increasingly, such plans are attempting to get out of the business of insurance, which is the business of taking risk, and passing the risk along to doctors, hospitals, and patients.

Health Maintenance Organizations (HMOs)

HMOs provide ``comprehensive'' medical care for prepaid monthly premiums. Services are provided by a specific group of medical professionals who receive a fixed, monthly payment for each subscriber, regardless of the services given or not given. And subscribers are limited to the physicians, hospitals, and other providers approved by the HMO.

Here's how that works: you choose a primary care physician from the list provided by the HMO. That doctor then becomes your ``gatekeeper'' and decides whether to recommend a test or procedure, to refer you to a specialist, or to admit you to the hospital.

At first glance, HMOs may seem like a way to save money. But in many cases, you are exchanging small savings for quality and choice. Here are some things to consider:

HMOs make more money by giving you less care. They get your payment in advance, then try to hold on to it by rationing or delaying care.

You have no guarantee that you can see the doctor of your choice. HMOs may prevent you from seeing the doctor or specialist of your choice who is not in their network.

Your doctor may be dropped or ``deselected'' from the plan for spending too much on your care. And many HMOs don't have to give a reason.

Many doctors are rewarded with an end-of-the year bonus if they cut back on care given. Referrals to specialists and lab studies come out of this bonus.

Many impose gag rules which prevent your doctor from telling you the truth about the plan. Or they may be prevented from telling you about procedures which may be available but not covered by the plan.

Total cost of the plan may be hidden. ``Washington Consumer Checkbook'' published findings that show that fees to join, deductibles, and co-payments frequently cost as much or more than the premium alone.

A committee, not your doctor acting alone, usually must approve your medical treatment. That committee may consist of an accountant, an HMO manager, and one doctor. And that committee may meet only once a month.

Since many of you receive your health coverage through your employer, you may not have much choice about whether to join an HMO. But you may have a choice between HMOs. If you are considering an HMO, here are some questions to ask before you join:


  1. Do primary care gatekeeper doctors get more money if they deny referrals to specialists, testing centers or hospitals? Please describe the existing incentives.
  2. What percentage of the monthly HMO premium actually goes to the doctors?
  3. What percentage of the monthly HMO premium actually goes to the hospital?
  4. What percentage of your primary care doctor's practice is HMO?
  5. What percentage of your primary care doctor's income comes from the specific HMO?
  6. How much money per month is actually received by your primary care doctor from your premium?
  7. Does the HMO contract with the doctor allow the HMO to terminate the contract if the HMO believes the doctor is overutilizing services?
  8. Does your plan have an ``experimental/investigative'' exclusion? Do you understand it? Can they explain it?
  9. What are the most frequently requested procedures presently being denied by your HMO on the basis of ``experimental/investigative'' or ``not medically necessary'' exclusions?
  10. Do the primary care doctors receive bonuses at the end of the year from the HMO if they limit referrals to hospitals or specialists?

(Courtesy: Mark Hiepler, Esq., 500 Esplanade Drive, Suite 1550, Oxnard California 93030)

Medical Savings Accounts (MSAs)

Medical savings accounts are gaining in popularity as an alternative that places the consumer at the center of the medical cost equation.

Rather than providing high-cost insurance policies with low deductibles and extensive benefits, employers instead provide each employee with an annual allowance of perhaps $3,000. That money is put into a savings account, called an MSA.

The employee is then responsible for paying his own medical expenses from the MSA until he exceeds the deductible.

If there is money left over in the account at the end of the year, the employee can save it, roll it over into a tax-deductible retirement account, or withdraw it. (Note: fewer than 13% of all insured individuals have annual claims in excess of $2,000.)

The employer saves money by purchasing lower cost catastrophic insurance. The system also saves money because it encourages people to shop around for their medical care. It is particularly beneficial to low-income employees because current traditional deductibles can cause hardship for those with little discretionary income.


Your insurance policy or managed care contract will spell out procedures for filing complaints or grievances. But the scales are tipped in favor of the company. If you're having problems, contact your state Insurance Commissioner to file a complaint.

At times, insurers refuse to pay for treatment they deem medically unnecessary or those considered experimental. If you are in a managed care plan, they not only can refuse payment, but refuse to provide the treatment itself.

Here are suggestions for fighting back:

Keep copies of all your bills. Check for simple clerical errors or mistakes in addition.
Ask your doctor to support your position. He can explain if there were special circumstances or why the charges were more than the insurer considers customary. (If your insurer claims your doctor is ``overcharging,'' don't assume the accusation is true; the insurer might be guilty of underpaying.)
Find out your plan's definitions of ``medical necessity'' and ``experimental.'' Your doctor can provide evidence to explain why the treatment was necessary and/or not experimental.
If your claim is denied as a pre-existing condition, ask your doctor for documentation that it developed after your coverage began.
Keep notes from all phone conversations and keep copies of all correspondence.


Medicare was enacted in 1965, promising universal medical care for the elderly (those over 65) at a reasonable cost without intrusion of the government into the practice of medicine. For the official explanation of coverage and procedures, refer to ``The Medicare Handbook'' available from your local Social Security office. But here's the fine print:

Your Rights Are Restricted When you turn 65 and turn your medical care over to Medicare, you lose many of the rights and choices you were entitled to as a private patient.


  • All doctors' charges for Medicare patients are now fixed by the government. Usually, they cover only 50% to 70% of the doctor's regular fees, and sometimes this does not even cover the doctor's overhead costs. As a result, many physicians must turn away Medicare patients because they can't afford to provide services. This greatly restricts your choice of physician.
  • If you have a problem with your bill, you must deal directly with your Medicare carrier. You lose your ability to negotiate with your doctor.
  • Medicare only covers those services and procedures that the government allows and may deny services that you and your doctor believe to be beneficial.

Private Contracting

There is an alternative called private contracting, in which the patient elects not to use his Part B benefits. Unfortunately, Medicare carriers state that patients must withdraw from Part B completely (and thus in most cases be uninsured for out-patient and physician services) in order to be free of the program's restrictions. It is hard to believe that patients eligible for Medicare could be barred from using their own resources to buy medical treatment, but many physicians are afraid of government penalties if they treat a Medicare beneficiary privately. Ask your doctor if he will allow you to pay him directly without filing a Medicare claim (if you wish to have this option). At the time of this writing, there is pending legislation in Congress that would guarantee your right to do so.

Medicare HMOs

Some insurers are offering managed health care plans for Medicare patients, which operate much like HMOs for the rest of the population. The government pays the HMO a certain amount every month on your behalf, and basically all your medical care is supposed to be provided for by the HMO.

Medigap Insurance

Medigap policies are offered to help cover Medicare copayments and deductibles. Generally, they cover only charges that are approved by Medicare. Many of these policies are so expensive that it is more cost-effective to bank the cost of the premium to cover your out-of-pocket expenses if and when you have them.


The medical profession has a myriad of tests available to help diagnose your problems. But to the layperson they may sound like alphabet soup. Some are expensive and can be intrusive and uncomfortable. To help you understand why a test is needed and know what to expect, ask these questions:

Why do I need this test? Your doctor can explain what he will be looking for, and why it is the most appropriate test for your situation. One of the most important things to know is what difference the test result will make in your treatment.
What can I expect during the test? Ask your doctor to explain the procedure, including pain involved and the amount of risk. Find out the amount of time needed so you can adjust your schedule. Be sure you understand the directions for any preparations that you need to make so that you will get the optimum results.
How reliable is the test? No test is 100% accurate, but you should know the limits.
What if I don't have the test? You have a right to refuse a procedure, but first find out the alternatives or risks.
How much will it cost? Prices vary. Remember, sometimes the cheaper test is not the best deal: low-cost contrast materials used in certain x-rays have a significantly higher risk of side effects, which can be quite serious.
How will I get the results? For especially important tests, such as pathology reports or x-ray reports, you may want to keep a copy in your records. That way you don't need to worry about it getting lost in a huge institution or about delays in getting the report to a new doctor. You should know that many institutions routinely discard x-ray films and recycle the silver after about 7 years. You may want to ask to keep a copy of the actual film. For some conditions like a nodule on a chest film, an old picture that shows the same nodule can save you months of worry or a risky and expensive work-up.
What is the physician's relationship with the laboratory? You have a right to know if the physician has a financial interest in the business. It may still be the best and most economical facility, even if the doctor owns it, but you should always be aware of your options.


An unnecessary hospital stay can be your most costly medical expenditure. Some patients are insistent on admittance, under the misguided perception that hospitalization will provide the most effective care. Before you enter a hospital, ask these basic questions: 1. Why am I going? 2. What will be done? 3. How long will I need to stay? 4. What results will it produce? 5. What will happen if I don't go? 6. Can I be effectively treated as an out-patient? 7. How much will it cost?

Keeping Track of Your Hospital Bill

A hospital punches in tens of thousands of bits of billing information into a computer every day. Mistakes are made. Demand an itemized bill and check it carefully for errors. Use a common sense approach -- make sure you were billed only for those services, supplies and medications you actually received.

To help keep track of you bill, you might want to keep a log of your stay, including: Your admission and release dates and time; type of room; dates in a specialized unit, such as intensive care; medications received; doctors' visits; physical or other therapy; laboratory tests, X rays, blood tests or other procedures; and personal items received, such as admission kits, thermometers, etc. If you question charges, talk to the billing office until they explain it to your satisfaction. If your insurer is paying the bill, inform them in writing of any inaccuracies.


Overall, life is 100% fatal. But most of us would like to postpone the inevitable as long as possible. The most important prevention must be done by the patient himself.

We all know we should eat a healthy diet, not drink to excess, get some exercise and refrain from smoking. Women should perform monthly breast self-examinations; men should check their testicles.

But here are some tips you might have forgotten:

  • Check your blood pressure. High blood pressure can lead to strokes, heart attacks or kidney disease, and it may have no symptoms at all.
  • Do a safety check in your home; most accidents happen there.
  • Wear seat belts and child restraint seats in cars. The simple act may save your life or prevent injury.
  • Keep current with immunizations. Even adults need boosters -- you may want to write the dates of your latest dose in the margin.
    • Tetanus (lockjaw). Adults should have a booster every 10 years, and in the case of a dirty wound if none has been given within 5 years.
    • Rubella (German measles). This otherwise mild disease is a common cause of birth defects; women contemplating pregnancy should be tested for immunity.
    • Polio. A booster dose of oral vaccine should be given in early adolescence and before travel to an endemic area.
    • Gamma globulin. Will help prevent or lessen severity if given soon after exposure to hepatitis. There is also a hepatitis B vaccine.
    • Pneumococcus. With increasing resistance to antibiotics among Pneumococcal bacteria, increasing use of this vaccine (now recommended for persons who have had their spleen removed or who are otherwise at high risk) might seem reasonable; however, the duration of effectiveness is rather short and boosters don't work well. Influenza. Yearly after age 65 or in other high-risk groups
    • Other. Recommendations change; ask your doctor to review your record at intervals.
  • Travel. If you are traveling to the tropics or other regions, plan well in advance, as several vaccines may be needed over a period of time. Malaria prophylaxis and precautions against parasitic diseases are very important. Ask your doctor to prescribe a travel kit of pain medicines, antibiotics, and other medications that you might need, along with directions for using them.
  • Know the number for the Poison Control Center. You'll generally find in the business section of you telephone directory white pages. Write it down. ____________________


Problem List

Ask your doctor to write down your problem list from your chart, especially if you will be traveling, along with important results such as EKG abnormalities, x-ray findings, etc.

Test Results

In addition to writing down your immunization dates above, you may wish to pencil in the results and dates of these other routine events:

Recommended Yearly:
blood pressure check ____________
glaucoma check (after age 40) ____________
rectal examination (after age 40) ____________
for women, breast and pelvic examination + Pap smear ____________
skin test for tuberculosis (if exposed) ____________
fasting blood sugar (if there is a family history) ____________
mammogram ____________
occult blood in stool (check for colon cancer, after age 35 or 40) ____________
other tests important in your case (clip in an extra sheet if necessary):

Adverse Reactions to Drugs
Write down exactly what happened, the date, and the name of the medication, before you forget:


Tape Libraries.

There are a number of telephone services that offer medical and health information through hospitals. One of the oldest is Tel-Med, a non-profit company which offers more than 500 taped messages on a broad range of topics.

Call hospitals in your community to find which offer the service.

Self-help and support organizations

There are hundreds of organizations providing information and support for every medical condition, dilemma or illness. Most have 800 phone numbers. Call the toll free directory assistance operator at (800) 555-1212, or contact the National Self-Help Clearinghouse, 25 West 43rd St., New York, NY 10036, 212-642-2944.


Patient Power by John Goodman and Gerald Musgrave (abridged), Cato Institute, 1994, available from AAPS for $5 per copy, $100 per box of 100 copies, call (800)635-1196.

Your Doctor Is Not In: Healthy Skepticism about National HealthCare by Jane M. Orient, M.D., Crown, 1994, available from author, $23 postpaid, 1601 N. Tucson Blvd. Suite 9, Tucson, AZ 85716, call (520)325-2689.

AAPS Pamphlets and Flyers:

  • Managed Care: Corporate Dream, Physician's Nightmare by Jim Morris
  • Ten Questions to Ask Before You Join an HMO by Michael Nahrwold, M.D. and Michael Klein, M.D.
  • How to Recognize a Coercive and Restrictive Health Plan by John and Alieta Eck, M.D.?
  • The Medicare Mess: A Patient's View by Phyllis Schlafly
  • Medicare Patient Freedom Resolution
  • Patients' Bill of Rights
  • Which Plan Would You Choose?
  • Huntoon Lampoons on Medicare and Managed Care

Call AAPS for a complete list of available videotapes, audiotapes, slides, and publications, (800)635-1196.

Visit our Worldwide Web Site at http://www.misnet.com/aaps

Additional copies of The Patient's Handbook are available for $1 each. Permission is granted to reprint as long as AAPS is credited and our address is included.

Pamphlet number 1049, May 1996

Reprints available from: Association of American Physicians and Surgeons, Inc.
1601 N. Tucson Blvd. Suite 9, Tucson, Arizona 85716
Telephone: (800)635-1196