How To Play HMO HARDBALL
From Exam Room to Courtroom Get Necessary Tests & Treatments
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YOUR HMO’S TOP 10 SECRET DIRTY TRICKS

Robert D. Finney, Ph.D., M.S.W.

Jacquelyn Finney, MPA

HMOs force doctors to play a game called HMO HARDBALL to deny patients medically necessary tests and treatments. The game is rigged. Patients lose. Why? HMOs and HMO doctors use secret dirty tricks to control the game.

My book, How to Play HMO HARDBALL, identifies all 30 secret dirty tricks that cause HMOs to win the game. The final score is usually:

Profit and Power for HMOs! Disease, Disability and Death
for patients!

All HMO patients suffer from HMO dirty tricks. HMOs follow business plans, not health plans. Healthcare provided to patients is a "medical loss" to their bottom-line.

I have selected 10 HMO secret dirty tricks that harm patients the most. These dirty tricks were all played on my family, especially on my wife, Jackie, who suffers from polio.


Dirty Trick #1: Mystery Contracts
.

HMOs have legal contracts with doctors that are written by HMO lawyers. These contracts control what doctors approve as "medically necessary" for patients’ health. HMOs and medical groups offer or deny doctors financial incentives such as bonuses, stock and profit sharing, if they order too many tests and treatments, too many referrals to specialists, too many prescriptions, and too many hospital visits. HMOs can also fire doctors by terminating their contracts. When HMOs have doctors by their paychecks, usually their hearts and minds will follow.

The legal contracts assure that HMOs and medical groups, not good doctors, approve:

  • What healthcare services are "medically necessary." (Tests and Treatments)
  • Where "medically necessary" healthcare services are provided. (Near or Far)
  • When healthcare services are "medically necessary." (Today, Next Month)
  • Who provides "medically necessary" healthcare services. (MD, Nurse, Aides)
  • How "medically necessary" healthcare services are provided. (Emergency Room, M.D. Office, Hospital, Telephone)
  • How long "medically necessary" healthcare services are provided. (Number, Frequency and Duration of Visits)

THE BOTTOM LINE: "APPROVAL’S NOT GUARANTEED, ‘CAUSE WE’LL SAY THERE’S NO NEED. GO READ YOUR CONTRACT." (The HMO Songbook)

Dirty Trick #2: Secret Police.

HMOs and medical groups maintain a computer "profile" of doctors’ practice patterns. This means that bureaucrats track whatever medical decisions your doctor makes. Periodically, doctors receive HMO report cards that either:

  • compliment them for making decisions to maintain HMO profits at levels defined in HMO business plan.
  • threaten them for busting the budget by treating patients compassionately and properly instead of impersonally as "cost units" dictated by HMO business plans.

Doctors have limited autonomy and cannot be patient advocates without risking retaliation (payback time) from HMOs and medical groups. The HMO secret police are always in exam rooms to watch what doctors do. It’s just the patients who are unaware that there is a bureaucrat interfering in the doctor-patient relationship who calls all the shots.

THE BOTTOM LINE: "IN THE HMO PRISON, PATIENTS NEVER GET TO MAKE A DECISION." (The HMO Songbook)

Dirty Trick #3: Ration the Compassion.

HMOs force doctors to ration their compassion in treating patients. Otherwise, HMOs will ration doctors’ salary increases, bonuses, perks and profits, or will fire them. HMOs make sure that doctors understand that "managed care" translates into "managing money and rationing healthcare."

HMO doctors base patient care on "outcome studies," which are presented as objective, scientific measures as to whether tests and treatments are effective in producing a positive "outcome" for patients. Outcome studies are junk science. They are designed to produce positive financial outcomes for HMOs, HMO doctors, and investors.

Outcome studies are rigged to show that cheap or none is better than expensive and more. Doctors tell patients that a test or treatment may only extend their lives by hours. An HMO bureaucrat actually made that statement regarding a new (and more expensive) type of Pap smear to detect cervical cancer.

The corrosive influence of money on the objectivity and integrity of highly regarded medical information sources has been widely reported and include the American Medical Association, drkoop.com, the New England Journal of Medicine and virtually every medical school in America. Patients must verify what HMO doctors tell them.

  • Use the Internet.
  • Use the library.
  • Use your brain.
  • Question! Question! Question!

THE BOTTOM LINE: "WHAT WAS GOOD FOR THE CAVEMAN IN NEANDERTHAL HEALTH PLANS IS STILL REALLY COOL." (The HMO Songbook)

Dirty Trick #4: Health Depot.

Doctors must meet "production goals" or face an HMO or medical group bureaucrat for a "counseling" (reprogramming) session. Doctors must get patients in-and-out without worrying what they do and how well they do it. Although patients are legally required to take "responsibility," patient initiative, including asking probing questions,

is discouraged. One of my wife’s doctors told her that asking questions interferes with the doctor’s ability to "help" her.

Patients are given a self-care manual and an "800" number to get healthcare from pre-recorded tapes or to speak with someone who is insufficiently qualified to diagnose and treat them. HMOs shove "Handbooks" at patients that preach and

demand patient "responsibility" without giving patients "authority" in medical decision-making.

Patients must know and enforce their rights and protections. Nobody’s going to do it for them. Patients must enforce their rights over and over again. HMO abuse is not confined to one-time only problems. The need for healthcare is continuous, not static, involving many areas at various times. Playing HMO HARDBALL has no time outs and has unlimited innings.

THE BOTTOM LINE: "YOUR DOCS ARE DICTATORS ‘TIL THEIR PATIENTS END UP IN HEALTH PLAN REFRIGERATORS." (The HMO Songbook)

Dirty Trick #5: Death is in the Details.

A quick death is a cheap death. HMOs imbue patients with HMO "values" so that they reject expensive treatment that may help patients to lead fulfilling lives.

As one insurance company VP put it: "Whoever can come up with a way…to get patients to do things or not do things at the moment of truth is going to be a trillionaire."

HMO "Bioethics" bureaucrats teach patients about Advance Directives and Living Wills. Patients are made to feel guilty about being an emotional and financial

"burden" on their families. Patients are tortured with the possibility that they will be forced to endure uncontrolled pain.

After a session of brutal HMO bioethics, the bureaucrats hand out (Advance Directive and Living Will) documents to be completed, to be given to next of kin/agent and to be placed in their official HMO medical record. Patients will write (as they have been programmed to do) that they not be resuscitated, not put on ventilators, not provided with hydration and nutrition.

HMO profits are protected, not the rights of scared, sick, or potentially sick patients.

HMOs know that hopelessness discourages patients’ will to live and the will to use treatments to prolong fulfilling life.

THE BOTTOM LINE. "DO NOT RESUSITATE. THAT’S YOUR HMO FATE." (The HMO Songbook)

Dirty Trick #6: Blame the Patient.

HMOs know that the best defense is a good offense. When patients assert their rights, HMOs and HMO doctors blame patients for protecting themselves. They are

very good at using labels to demoralize patients. Patients who have figured out how and why HMOs are mistreating them are called "HMO Bashers." Patients who are vocal and proactive (especially women) are bashed with labels such as "hysterical, neurotic, complaining and demanding." HMO doctors write these labels in patient medical records. "Patient Bashing" is cheap and effective.

Patients are threatened with being "blackballed" by all the doctors in the medical group, if they "burn their bridges" by demanding quality care. My wife and I were.

We were also told that we wanted "favoritism" and had "unrealistic standards." The HMO’s Medical Director told us to choose another health plan.

We replied that the facts showed that we were not to blame. We demanded appropriate standards of care. If HMO doctors didn’t want to fulfill HMO advertising promises and abide by the terms and conditions of our contract with the HMO, they should quit the HMO and medical group. Don’t bash us!

THE BOTTOM LINE: "THE SAME-DAY MASTECTOMY CUTS COSTS FOR YOUR SURGERY. SMILE LIKE GOOD LITTLE GIRLS!" (The HMO Songbook)

Dirty Trick #7: Get ‘Em Out

HMOs and HMO doctors believe that HMO healthcare is warfare. In fact, an HMO doctor referred to himself as a "foot soldier" and patients as "pawns." Patients who demand medically necessary healthcare and learn how to play HMO HARDBALL are enemies. HMOs and HMO doctors must get ‘em out of the HMO, before they drain profits or cause losses.

How do HMOs get ‘em out?

  • Send them to the worst doctors in the medical group. Rudeness and incompetence work wonders.
  • Set up an obstacle course to cause difficulty in making appointments. Cancel appointments. Frustration is a magic bullet. (Hopefully, patients won’t download and use HMO HARDBALL’s "Appointment Scheduling Complaint Form.")
  • Terminate their care. My wife’s gynecologist wouldn’t see her, after she had caught him in lies and medical mistakes. He claimed that there was a "serious erosion of trust." We documented that he had caused it. The Chief of OB/GYN is now my wife’s doctor.
  • Trigger the "involuntary termination" clause in the contract. HMO contracts state that patients can be kicked out of the HMO, if they have "failed relationships" with their doctors. We showed that HMO doctors caused failed relationship, not us. This term was deleted from our HMO’s contract.

THE BOTTOM LINE: "WHEN PLAIN FOLKS HOWL, THEY GET SENT TO A VET." (The HMO Songbook)

Dirty Trick #8: Gotcha!

HMO doctors keep patients on a short leash to show them who’s boss. GOTCHA helps control patients by undermining their self-confidence. My wife used my book’s "Patient Pressure System" to obtain out-of-plan referrals for DEXA testing to

diagnose osteoporosis. The referring HMO doctor was mad as hell about having to approve the tests.

He called with the test results. Yes, she had "some" osteoporosis (However he failed to inform her that she was at 26 x normal lifetime risk of fracture). She asked about drug therapy and other solutions. The doctor’s answers:

  • The solution is wearing low-heeled shoes, not bone-building drugs. GOTCHA!
  • You don’t meet HMO "guidelines" for further testing. GOTCHA!
  • Your condition is "nihilistic." (Worse than hopeless) GOTCHA!

We used my book’s Patient Pressure System to convince the HMO’s Chief of Internal Medicine to refer her to the medical group’s expert in osteoporosis diagnosis and treatment. The result? Drug therapy, further diagnosis and careful follow-up.

THE BOTTOM LINE: "HMOS ABUSE YOU, BLANTANTLY SCREW YOU. THEY SURE CAN DO IT SWELL." (The HMO Songbook)

Dirty Trick #9: The Records Racket.

Medical records justify everything doctors do or don’t do. They include hardcopy documents, electronic medical records and tape recordings ("for quality assurance purposes only"). Medical records are the key to winning appeals, arbitrations and lawsuits. HMO lawyers teach HMO bureaucrats and doctors how to use the HMO poison pen to write medical records that favor them, whether the statements are true or untrue.

HMOs maintain files on patients in addition to their official medical records. Patients have no idea what the contents of these files are, because they are classified as "

"administrative," or some other category, not medical and not subject to patient access. HMOs maintain medical records under the auspices of HMO lawyers. Legal privilege prevents patient access.

If records are incriminating, they are intentionally "missing" and patients are told that the records aren’t "important." Patient calls (e.g., to the HMO hospital emergency

room) are taped, but HMOs refuse to produce the tapes unless patients initiate legal action. All this happened to us. That’s why my book and website contains documents for patients to complete and place in their HMO medical files.

State laws exist to force HMOs and HMO doctors to produce records. Enforcing these laws is virtually impossible, because HMOs often co-opt regulatory agencies that by law are supposed to protect patients.

Federal and state regulators follow the money and leave government to go to work for HMOs. Consumer advocates do the same thing. The former Director of Common Cause "(a consumer advocate organization) is now the President and CEO of the California Association of Health Plans (a big-time HMO lobbyist), making big-time bucks."

THE BOTTOM LINE: "CONTROL OF MEDICAL FILES CAUSES HMO SMILES." (The HMO Songbook)

Dirty Trick #10: Sounds Fair, Seems Fair, Isn’t Fair. GOTCHA!

HMOs produce warm, fuzzy ads to lull patients into a false sense of security to discourage logical thinking. These "infomercials" are hype, but are vital to enrolling new patients (i.e., producing new business income). At least one court has found that these fraudulent representations aren’t fraud at all. They are simply "puffery," an "OK" word to excuse HMO lying.

Patients must wake up. They must understand that the standard for honesty in what is represented to be the best healthcare system in the world is the same as that which prevails in used car advertising.

Patients are told that their care is "in the hands of doctors." That’s the "branding" slogan of our HMO, Kaiser Permanente. We found a document in which our HMO’s lawyers instruct HMO doctors not to approve emergency room care for patients. Doctors in our HMO are not able to approve payment for ER care. That’s done afterwards, by an HMO committee. The Kaiser Permanente Emergency Department Chief said that on tape.

Seniors shouldn’t believe for a second that Medicare protects them from HMO dirty tricks. HMOs defraud vulnerable Medicare recipients to enroll in the HMO. For example, Foundation Health sales representatives take the old folks out for breakfast at CoCo’s to lure them into signing up for the HMO. The enrollment application states that the applicant has reviewed the contract (the Evidence of Coverage) prior to signing the application.

What’s wrong with this picture? The Evidence of Coverage isn’t distributed for the applicant to review. It’s not distributed until after the enrollment occurs. (To view more Patient Rights Violations, visit my website at www.hmohardball.com. Click on HMO Violators to read authenticated violations.)

THE BOTTOM LINE: "OUR LAWYERS ARE MEAN AND THEY’RE PAID MORE TO BE MEANER. THEY TAKE PATIENTS TO HEALTH PLAN DRY CLEANERS." (The HMO Songbook)


DON’T FALL FOR THESE HMO TRAPS!

Protect yourself!

 

Created and produced by Robert and Jacquelyn Finney, CounterPoint Communications.

Website consultant Ray Koch, Groundswell Productions

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