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Former HMO reviewer: Patient died, but HMO saved money
April 15, 1997
Web posted at: 11:52 p.m. EDT (0352 GMT)From Correspondent Don Knapp
SACRAMENTO, California (CNN) -- Dr. Linda Peeno said she's haunted by a health insurance decision she made 10 years ago that she believes led to a patient's death.
Peeno told a California Assembly Health Committee that she was working part-time as a medical claim reviewer for Humana, Inc., a major health maintenance organization, or HMO.
"I was told to find a way to get out
of paying it."-- Dr. Linda Peeno
She explained the decision to deny the man coverage for a heart procedure.
"The pressure was put on me that this was an expensive procedure. It was brought to me, and I was told to find a way to get out of paying it," Peeno told CNN before the hearing.
The committee is considering a bill that would block HMOs from denying anyone medical treatment unless they were first examined by a doctor. The bill's author says Peeno's story reflects what she hears from constituents.
"I have constituents calling us, and saying that they know that they are not receiving the best of care, that their own doctor's decision is being overturned by someone else," said Liz Figueroa of the Assembly.
Peeno said her decision to deny a heart transplant cost the patient his life, but saved the company between $250,000 and $500,000.
"'We can't pay for this...we got to figure out a way not to pay for it.'"
-- Comments Peeno attributes to Humana
"Someone came in my office and said, 'Have you called yet about this case? ...we can't pay for this. This is going to occur at a hospital with which we don't have a contract, and full charges, and we got to figure out a way not to pay for it,'" Peeno said.
But Humana disputes Peeno's story. In a written statement, the company claimed "she was never in a position to be the final arbiter of any medical, health care or insurance matter."
The company also denies the incident ever occurred, stating, "We ... have no records to support that this case even existed or what the resolution was or why."
The California Association of Health Plans would not speak directly to Peeno's allegations, but said having doctors make a physical examination of patients before denying coverage would be too costly.
Related stories:
- Are HMOs the wrong prescription for patients? - April 3, 1997
- Poor and elderly do worse in HMOs - October 1, 1996
Related sites:
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- Humana, Inc.
- California Department of Health Services
- Health Care Consumer Protection Initiative - Prop. 214
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