Advocating for Care

My Patient Rights > Advocating for Care

What happens if I cannot get the treatment I need?

If your doctor has ordered a treatment or medication but your insurance company won’t approve it, determine why they aren’t approving it – ask why! Often insurance companies have “prior authorization” requirements that mean the doctor needs to request authorization. Insurance companies may also have steps or other treatments they want you to try before one that is more expensive. Once you find out why the insurance company won’t pay for a treatment you have several options:

  • Ask if there is an alternative treatment they will pay for, and check with the doctor to see if that will work for you and your care plan.
  • Ask the doctor to contact the insurance company and ask for the treatment to be covered.
  • File a complaint with your health insurance. If you receive a decision that you disagree with, you have the right to file an appeal.
  • File a complaint with the government agency in your state that oversees health plans. Proceed to the file complaints area of this page by clicking on your state on the map below.

Medications are sometimes switched for reasons other than medical reasons. This is called nonmedical switching and 10 states have laws against it. This can be a particular problem for people who have chronic illnesses and have found a medication that makes their condition stable. If this happens to you, let your doctor know what has happened. A provider can often file an appeal about the change in medication. If this appeal is not successful, proceed to the file complaints area of this page by clicking on your state on the map below.

If it is your doctor or other provider who is not providing the treatment you need, ask why. You can request a second opinion or another doctor. See below for information on how.

What do you do when you want to change doctors?

Work with your insurance company to identify a new doctor and determine how to change doctors. (Find the insurance company’s phone number on your insurance card.) Some insurance providers or policies will have restrictions on changing your doctor and may require you to choose an in-network doctor. Other policies, such as PPOs, generally allow you to choose doctors with fewer restrictions.

Once you’ve identified and chosen your new doctor, check their availability. You don’t need to say anything to your former doctor but collecting your previous medical records from them.

Your doctor won’t send you to a specialist you need?

Have you been specific with your doctor and said the words, “I need to see a specialist”? If you haven’t done that yet, do so immediately. If your doctor still refuses to send you to a specialist, ask for their refusal in writing. Call your insurance company and ask for their help to access the specialist, get another opinion, or change doctors. If none of those steps work, file a complaint with the doctor’s medical group (it should be listed on your insurance card). You can also file a complaint with the insurance company for not allowing you to see the specialist, not allowing a new doctor, and anything else they said “no” to that placed a barrier to you seeing a specialist. Finally, using the map of states on this website, find your state and file a complaint with the state agency overseeing insurance.

When can you ask for a second opinion?

You may for a second opinion if:

  • Your primary care or specialty doctor is unable to diagnose your condition.
  • Think you’ve been misdiagnosed.
  • Want another opinion on how to treat your condition.

It’s okay to tell your doctor you want a second opinion. There’s no offense to be taken and your doctor may even You can tell your doctor you want a second opinion. They may offer you a recommendation or you can pick your own doctor to get the second opinion from. Before you choose your second opinion doctor, check with your insurance company to see if they have any restrictions on second opinions such as specific networks from which to choose a doctor for your second opinion. There may be some costs associated with seeking the second opinion particularly if you choose to go out of network. Be sure to ask your insurance company about cost.

What to do when you can’t get in to see a specialist or can’t get a test done in a reasonable amount of time? Most states require timely access to care, but timely access to care can be difficult to find, particularly in rural areas. You can click here to see what that means in your home state. Nationally, we are short on providers in many specialties and geographic areas. If you cannot get access to care in reasonable amount of time, here are some options:

  1. Ask to be put on a call list for appointment cancellations at that office or company.
  2. Call the office or company every day asking about cancelled appointments.
  3. Ask the insurance company to authorize a provider further away or out of network. (If you are able to travel to appointments with a provider further away.)
  4. File a complaint with the insurance company. (Choose your state on the map below to find out how.)
  5. File a complaint with your state agency that oversees health insurers in your state. (Choose your state on the map below to find out how.)

What to do when you get a surprise bill, or a larger bill than expected? 

If you receive a surprise or unexpected bill, or the amount you are billed is more than what you were quoted or expecting, you may file a complaint, appeal, or grievance. As of January 1, 2022, patients are protected by the federal No Surprises Act, which protects people from surprise medical bills.

To get started on fighting a surprise bill, contact your insurance or the No Surprises Help Desk at 1-800-985-3059, 7 days a week: weekdays from 8:00 am – 8:00 pm Eastern Time (ET), and weekends from 10:00 am – 6:00 pm ET.

More information on surprise billing and your rights are available here.

Words and terminology you should use to encourage providers to act on your health issue:

  • If you are asked how much pain you are in, do not minimize your pain. There is no reward or upside to minimizing it. In fact, downplaying your pain may lead health care providers to think your health issue is not serious. They will likely use a 10-point scale with 10 being the most pain. Some providers use a visual scale with faces. Check them out online and give an accurate assessment to your providers here.
  • Ask yourself the following questions and tell your doctor:
    • What can you no longer do?
    • What everyday activities are painful?
    • Has this affected your work?
    • How have you adjusted your life to accommodate the symptoms, pain, or injury?
    • How long has this been going on? (Mention how long you’ve been asking for help. Tell them what steps you’ve taken to correct this, people you’ve talked to, tests you’ve taken, over-the-counter pain pills you take to manage related pain.)

If these suggestions don’t resolve your issue or you wish to share your story, please go to our Get Help page. My Patient Rights is here to help you file a complaint. We want to be sure you are taking the steps necessary to ensure you receive the medication and treatments you need and deserve. Click on your state below to find out how.