(MONEY Magazine) – If you think your doctor always knows best and that only the truly foolish or congenitally obnoxious painstakingly research their health problems, think again. If Mary Lee Horton had not questioned the treatment her children were getting for a rare blood disease, daughter Kate, 4, pictured on the opposite page, might not be alive today. (As it was, Mom's intervention came too late to save Kate's twin sister Sydney; she died three years ago.) True, such situations are rare. But you and your family will benefit if you aggressively act to solve more mundane medical problems, such as squeezing special treatment out of a tightfisted health maintenance organization or disputing a health insurer ruling that shortchanges you. Fact is, you no longer have a choice. Although it seemed unlikely at press time that a health- care reform bill would emerge from Washington this year, market forces will continue to push free-spending American patients toward greater price- consciousness. Already, insurers that don't scrutinize medical treatment by reviewing doctors' services are practically extinct. They account for just 5% of today's health insurance market. That's down from 35% in 1988 and virtually 100% 20 years ago. No matter how competent your family physician is, he or she is probably increasingly pinched by insurers and too swamped by paperwork to act as an informed advocate for every patient. So to get the care you desire -- and deserve -- you have to look out for yourself. Unfortunately, it's not easy. But armed with the right information and some gumption, you can become well qualified to take a major role in managing your care. Furthermore, it's getting easier to educate yourself. We've organized our advice by the three types of health-care skirmishes you and your family are most likely to encounter: confrontations over the quality of your care, its cost and the types of benefits your insurer will cover. In the accompanying boxes, you'll find stories of families who waged just such battles -- and won.

Getting the best care The pressured atmosphere in many hospitals, labs and doctors' offices these days often makes you feel as though everyone must act immediately. In fact, very few medical treatments or tests are so time-sensitive that you must make an on-the-spot decision. So examine your options. For instance, if your doctor presents only one possible treatment, push him or her to tell you whether there are others and how they differ. Alternative therapies don't necessarily mean embarking on New Age regimens. You may favor a more conservative approach than your doctor does. For example, three years ago, Group Health Cooperative of Puget Sound, a Seattle-based HMO, stopped routinely testing male patients over 65 for prostate cancer. Instead, it asked each man whether he wanted to be tested. Because this type of cancer is generally very slow-growing in symptomless cases, treatment hasn't been shown to lengthen life and carries significant risks of its own, including the death of one or two of each 100 patients as a result of surgery. After learning about the hazards of treatment, nearly 50% of the HMO's patients passed up the test. The key to making wise medical decisions is getting clear, up-to-date information. One appealing new way to gain knowledge is through so-called interactive videos that run on computers with video disks. A patient views others discussing the merits and drawbacks of various treatments they chose for the same ailment, then uses a touchscreen to describe his own circumstances. Moments later, the computer prints out a customized profile of his risk factors. Using data from the Foundation for Informed Medical Decision-Making, a Hanover, N.H. research and educational center, Sony is marketing programs on benign prostate disease, breast cancer, lower back pain and mild hypertension -- with videos on other topics, such as hormone-replacement therapy and stable angina, in the works. Sony promises all will be updated each year with the latest medical data. The programs are currently available at more than 100 hospitals and HMOs around the country, but you'll need a doctor's prescription to see one. For viewing locations, call 603-650-1180. Much of the data in Sony's videos has been generated by a relatively new field called outcomes research, which tries to quantify how surgery, drugs and other treatments pay off in medical, social and emotional terms. This approach to treatment is controversial, since research often disagrees. Yet it has already contributed to some generally accepted "clinical guidelines" to help doctors decide when to use -- and when to forgo -- various treatments. These guidelines are often available in consumer-friendly pamphlets from self-help groups, medical specialty boards and government offices. For serious medical matters, you may need to consult other sources aside from your family physician, including one or more specialists. This process can get tricky, since second opinions conflict with first ones about 15% of the time, on average. To minimize the crossfire from dueling medical opinions, arrange for all the doctors working on your case to sit down with you at one time, if only in a phone conference. Four years ago, Dorothy Rodman, a New York City associate film director, learned that she had breast cancer. Rodman, who had long suffered from emphysema, was concerned that the standard radiation treatment accompanying removal of a tumor might destroy precious lung cells. To decide what treatment to pursue after surgery, she met simultaneously with her internist and cancer surgeon. The three of them decided against radiation. Instead, the specialist suggested tamoxifen, a potent anticancer drug, plus semiannual mammograms. "It's not a perfect solution, but it's the one that works best for me," says Dorothy, whose cancer is now in remission. You may also be able to call in a health-care adviser. A small but growing number of insurers and employers provide telephone consultation services that offer referrals, recommendations and even medical data to help you sort through options. For instance, more than a million Blue Cross customers in California, Kentucky, Oregon and Pennsylvania can call Personal Health Advisor, a free 24-hour hotline, to talk to registered nurses on topics ranging from whether to see a doctor about a rash to how to find a top specialist. You also can get specialized information from a research service, such as Planetree (415-923-3680), a medical library affiliated with California Pacific Medical Center in San Francisco. For the price of a phone call, they'll refer you to support groups, such as the one that put Mary Lee Horton on the trail of a cure for her twins' blood disease. They'll also give you the names of doctors who have written studies on treatments for your particular condition. For a $20 to $100 fee, Planetree's researchers will even compile medical literature on your problem.

Keeping your costs under control Becoming a confident health consumer can automatically reduce your medical bills by encouraging you to rely on your own judgment rather than rushing off to see your M.D. According to studies by the actuarial consulting firm Milliman & Robertson, at least 10% of doctor visits are unnecessary. To help you distinguish between situations that merit professional care and those you can handle, get a self-care manual, such as the two-volume Healthwise Handbook and Healthwise for Life ($14.95; Healthwise, 1602 W. Franklin St., Boise, Idaho 83701). If you are among the 58% of the U.S. population whose insurance coverage requires you to pay a deductible (typically $250 to $1,000 annually) plus 20% or more of costs, or the 15% that lack any health insurance, learning to question your doctor's fees can save you a bundle. Studies show that charges + for the same service can vary by as much as 733% from one physician to the next. In St. Louis, for example, a patient can pay anywhere from $15 to nearly $110 for a routine office visit, says Medirisk, a health-care pricing firm based in Atlanta. Always ask your doctor for a schedule of charges before you undergo any procedures. Then call at least two other area physicians to compare prices. If your doctor insists on a fee schedule that seems out of line, consider changing doctors. It's getting easier to compare prices because some local consumer or business groups now compile price guides. In Atlanta, Boston, Pittsburgh and St. Louis, a $3.95 newsstand magazine called Health Pages lists fees for hundreds of local doctors, hospitals and insurance plans. Otherwise, you can call the Health Care Cost Hotline (800-383-3434) in Portland, Ore. to get data on the median fees for medical and dental services in your zip code. Average charge per inquiry: $6. There's also a quick way Medicare beneficiaries can spot excessive doctors' fees. Because recent federal rules limit the amount doctors can charge Medicare patients, if your share of the bill comes to more than 31% of the total fee, you can conclude that you're being overbilled and tell your doctor that he is legally required to give you a refund. You also should be sure you're collecting all the insurance payments you've filed to receive. If you have many medical bills and find it easier to keep records on your home computer instead of in folders, try a claims-tracking software program such as ClaimPlus ($74.95; 603-726-4700). If you're unable to do this complex job yourself -- and you're willing to pay a fee equal to 10% to 15% of your reimbursements -- you can hire a claims-filing service, such as Medical Insurance Claims (800-355-2662). Obviously, you can also control costs through your choice of coverage, particularly if you pay your own premiums. For instance, if you use a lot of medical services, look into an HMO where comprehensive care is covered at a flat rate. Currently, a family of four might have to pay about $400 a month for an HMO but would face few out-of-pocket costs. If you generally don't need much medical care, because, say, you're under 35 or you rarely get sick, consider a traditional policy but sign up for the highest deductible you can afford. A major-medical policy might cost a family of four $371 a month with a $500 deductible but only $190 a month with a $2,500 deductible. The $181 monthly savings ($2,172 a year) can be set aside to help cover any bills you do incur. You may also be able to trim premiums by as much as 50% by cutting out smoking, losing weight or reducing blood pressure or cholesteral levels (see box on page 116). Agents and insurers usually won't volunteer such cost-saving strategies, so always ask what you can do to trim premiums.

Getting the coverage that you need The simplest way to deal with claim denials by health insurers is to resubmit your claim, adding a bit more information. Happily, according to the Medicare Beneficiaries Defense Fund (800-333-4114), a consumer group, 78% of Medicare claims that are denied at first get paid fully or partly on the second try and 67% make it on the third. If you are clearly entitled to a denied benefit -- it's included in your policy and the care you received is common for your condition -- all you probably need is persistence. Though it's not widely known, your insurance company may even be willing to pay benefits not included in your policy if the insurer believes they will avoid more expensive treatment down the road. Examples are outpatient psychotherapy and rehabilitative services, both of which could forestall a big-ticket hospital stay. If you think you can make such an argument, speak to a supervisor and try negotiation. Comparing a $200 weekly bill from a psychotherapist with the $2,500 or more per week that a private psychiatric hospital would charge, for instance, may get you what you want. Managed-care plans can become a fiery battleground when patients are unsatisfied with the plan's doctors and want their insurer to pay for out-of- network care (see the box on page 119). There are no surveys on how often such requests are approved, though the share is probably minuscule. But here again, it may pay to negotiate. If you may need a high-risk, high-cost treatment, say, for cancer, you can appeal to the Medical Care Ombudsman Program (301-657-0404). It enlists independent doctors to review patients' cases and intervene on their behalf when appropriate, often for free. (See Editor's Notes on page 9 for details.) The best last-resort strategy for getting paid is to make it costly for your insurer to say no. In extreme cases, assuming you've got the stomach for it, threaten a lawsuit, instigate a media blitz, or ask your elected representatives to intervene. Indeed, a recent Duke University study found * that nearly 50% of breast cancer patients' bone marrow transplant claims that were initially rejected by insurers were okayed after the patient hired a lawyer. Over the next few years, more and more tools for smart medical shoppers will become available as the information revolution and health-care reform advance. You and your family will benefit from them, however, only if you start behaving like a canny consumer rather than a passive patient.