| Netfolio
Insights: |
|
|
Getting
HMOs to Pay Up
Before the Costs Kill You |
 |
|
|
|
|
|
|
Robert
Finney
|
|
Many
HMOs talk a great game about their coverage and
low premiums. But they don't always deliver on benefits.
If you belong to an HMO, you are likely to face
a denial for care at some point–and not just
for experimental treatment. HMO's have often denied
payments for screenings and procedures such as a
colonoscopy, MRI and out-of-network referrals.
Netfolio asked Robert Finney, PhD, for ways to limit
the odds of being denied payment for treatment and
how to fight the bureaucracy if your HMO refuses
to budge. |
|
| Before
a health crisis strikes |
|
Ask
how your doctor makes medical decisions. The
goal here is to find out how your doctor's contractual
relationship with his or her medical group or HMO
affects his medical decisions. Otherwise, he may
fail to be a strong advocate for you should you
face a tricky payment situation.
Put the following questions to your primary-care
doctor in writing:
1. Does the HMO maintain a profile of your practice
patterns? Do they profile your patterns of patient
tests, treatments, hospitalization, drug prescriptions,
emergency room referrals and specialist referrals?
2. Does the HMO offer or deny you financial incentives,
such as an annual bonus or profit-sharing, after
it reviews your practice patterns?
3. Does the HMO terminate your employment contract
or discipline you if you don't cooperate with
them?
4. Does the HMO have any gag clauses? These
are clauses written into a physician's contract
that limit him from telling you about alternate
tests and treatments that the HMO does not pay for
or recommend.
Your
doctor may balk at answering these questions.
He may even try to make you feel ashamed for asking
them.
An elegant reply: "I want to know
that as my doctor, you will go to bat for me in
a difficult medical situation. My HMO handbook
tells me I have a duty as a patient to take responsibility
for my condition. That's what I'm trying to do."
If your doctor refuses to respond to these and
other medical questions ask that he place a list
of your questions and his answers in your medical
file. This will document your attempts to take
responsibility as your HMO has instructed.
If you face a medical problem in the future, your
doctor knows he will have to account for why he
wasn't forthcoming on these basic questions.
|
|
|
| What
to do if you're denied treatment |
|
Make
you doctor prove you don't need the treatment.
HMO primary-care doctors won't stop you from seeking
care if you pay for it out of your own pocket. But
they will deny you a referral when they allege the
treatment you request isn't necessary. That means
the HMO won't help pay for the treatment.
Pressuring your primary-care doctor to change his
or her mind is a more effective approach than immediately
going over his head to the appeals process.
The goal is to make the doctor see that what is
in your best interest is also in his best interest.
My advice:
1. Contest the facts. Often, doctors who
refuse to give you a referral may not be aware of
current medical facts or let cost-control incentives
affect their diagnosis and treatment plans.
2. Learn everything you can about your condition
or disease. Dig up evidence from a number of
sources supporting the tests and treatment you need.
Then present your facts in writing in a cooperative,
non-confrontational way.
a. Web sources: These high-caliber sites
are as free from conflicts of interest as possible:
Healthfinder
Medline
Plus
3. Ask for a detailed response with precise
definitions and authoritative sources if your
doctor refuses. Ask questions about the effect
of HMO financial incentives on his medical decision
so you can continue to build your paper trail
and hold your doctor accountable.
In my experience, doctors often relent and give
you what you need rather than having to support
their initial decisions, which may be based on
financial incentives.
Case in point: My wife recently felt she needed
a colonoscopy. She is a patient with a high-risk
for colon cancer. Her father died of the disease.
Medical experts advise that everyone over age
50 should get this procedure every five years
to 10 years. However, her primary-care doctor
told her that his medical group's practice guidelines
said the test was unnecessary in her case.
We gathered data from the American Cancer Society
and showed him research that conflicted directly
with his decision.
Moreover, we asked the doctor to provide authoritative
sources on which he based his decision, as well
as alternatives to the treatment and the advantages
and disadvantages of each one.
The doctor gave her a referral and a go-ahead
for the test immediately.
|
|
|
| If
your HMO doctor still says "no" |
|
File an appeal according to HMO rules. But
don't let the HMO control the process. One way to
do this is to avoid using just the HMO appeals forms.
They are unfocused and written to favor the HMO.
Instead, include your own documentation. View samples
of forms you can attach to the HMO's forms at www.hmohardball.com
(Click on "Hardball
Helpline").
Your package to the HMO should include:
1. A letter offering a complete factual
and analytic basis for determining that the test
or treatment you need is medically necessary.
2. Copies of all written documentation
between you and your doctor.
3. Copies of any supporting documents you
presented your doctor.
4. A second medical opinion, if you have
one.
Follow
the rules of the appeal.
Not doing so can cause long delays. Read the Evidence
of Coverage (EOC) booklet which plans are required
to provide to each enrollee and your contract. It
describes the steps to initiate an appeal.
Every health plan has a different format. Some may
give you only a limited window of time to file the
appeal.
Understand why you were denied. Denials
are always based on two factors:
1.
The test treatment isn't a "covered benefit"
in the contract and/or
2. The test/treatment is not "medically necessary."
You
must base your appeal on why one or both of these
two factors are being wrongly interpreted in your
situation.
In general, an HMO should respond to your complaint
within a reasonable time–usually 30 days. In
emergency situations, you can request an expedited,
72-hour response.
Write your appeal in HMO-speak. Use the
official benefit or coverage terms from your Evidence
of Coverage (EOC) or Summary Plan Description (SPD).
Always refer to the document, the section number
and the page where you found the quote from your
health plan. State why you believe your treatment
is "medically necessary," "a covered
benefit" or, if it applies, is not an "experimental
treatment."
Keep well-organized, neat records. Clearly
written documents are the basis of most successful
appeals and grievances.
HMO's often win because they have more extensive
hard copies, electronic medical records and tape
recordings to support their denial of care.
Remain civil and polite–no matter how
great the stress. Write all your letters with great
care. Construct them as if they one day will be
read by an arbiter or a jury as evidence.
Avoid cursing or screaming during phone calls to
the HMO, because conversations often are recorded.
During appeals, HMOs will use any pretext to paint
the patient as hysterical or a managed-care basher.
You may want to tape record your own conversations
to have a record of what was said. But be sure you
inform the other party you're doing so.
Stay put while negotiating your complaint.
If you leave the HMO plan during a dispute, your
appeal will likely to fail. You'll have much greater
leverage if you're still a member. If you believe
that your health will be damaged, seek care outside
the HMO and pay for it yourself. Then retroactively
seek reimbursement in your appeal.
Ask that HMO reviewers have medical expertise
relevant to your problem. If you are a diabetic,
you want to have an endocrinologist involved in
your case's decision. |
|
|
| What
to do if your HMO appeal fails |
|
Call state agencies that oversee HMOs if
your health plan is unresponsive to the appeal,
fails to meet legal time limits or doesn't offer
a satisfactory resolution.
Each state has a Department of Insurance or Health
Agency that regulates HMOs' activities. Submit an
"external appeal" to them. If they think
your claim is legitimate, they'll investigate whether
your HMO has complied with its own policies and
state law, and whether correct medical decisions
were made.
If the HMO did not comply, the state can order corrective
action, including making payment on valid claims.
However, if your employer is self-insured and simply
uses an insurance company to administer claims,
state protections may not apply. You'll need to
consult a lawyer.
Seek outside arbitration, but don't proceed
without careful consideration and legal advice.
Many health plans actually mandate a procedure called
"binding arbitration" as the last step
for the resolution of appeals and claims.
These are legal proceedings in which an independent
arbiter, often a retired judge, listens to each
side's claims and makes a final decision.
If arbitration is not required, consider filing
a lawsuit. Lawyers should be consulted prior to
either arbitration or a lawsuit. Select your lawyer
as carefully as you select your doctor. |
|
|
| Where
to turn if you need more help |
|
Here
are my favorite helpful Web resources:
The
Center for Patient Advocacy is a private, non-profit
grassroots organization founded to represent the
interests of patients nationwide. It offers the
latest news about health-care issues, as well as
links to important legislation and ways to check
out your doctor.
Health On the Net Foundation Code of Conduct.
A site that helps patients evaluate the reliability
and quality of many medical and health web sites.
|
|
|
|
|
|
Netfolio Insights features the opinions of many
different financial experts. The views expressed
in these articles do not constitute the investment
advice of Netfolio, Inc. The articles are not
a substitute for individualized professional advice
when investing, managing or spending your money.
|
|
|
|
|
|
|
|
|
|
|
| About
the Expert |
| Robert
Finney, PhD, is a former manager of health-care
cost containment at a Fortune 500 company.
His wife is a former Federal healthcare regulator.
They run www.hmohardball.com, which teaches patients
how to pressure HMOs and HMO doctors to provide
care. The site is entirely self-financed and free
from conflict-of-interest. Dr. Finney is the author
of How to Play HMO Hardball (CounterPoint
Comm). |
|
