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| health > story page |         |
What to do when your HMO says 'no'October 4, 1999
By Kathleen Doheny (WebMD) -- Has your health maintenance organization (HMO) told you "no" lately? Maybe that's the response you got when you asked to see a specialist. Or perhaps you requested a specific prescription medicine you've used in the past, but this time, you were turned down because the drug is not on the HMO's formulary -- a list of medications that the plan covers. Like many consumers, you may just grumble and think about switching health plans. But consumer advocates have another idea: Don't take "no" for an answer -- at least not until you find out why your request was denied and whether you can get the decision reversed. "It pays not to be silent," says Janet Backes, a spokesperson for California Health Decisions, a nonprofit advocacy organization based in Orange, California. If common requests like wanting to see a specialist or obtaining a specific medication are denied, the first step is to find out who said "no," according to Dr. Alan J. Steinberg, an internist in Marina del Rey, California, and author of the book "The Insider's Guide to HMOs" (Plume, 1997). For instance, was it a committee within the plan that gave the thumbs down? Once you've learned the "who," then try to find out the "why." You will likely get a form letter explaining the denial, but that's not good enough, Steinberg says. "Ask for a specific letter, signed by the doctor or group of doctors [who made the decision]." At this point, he says, HMO officials might decide it's less of a hassle to grant your request than to continue fighting. If you have a good relationship with your primary care doctor, ask him or her to advocate for you, says Susan Pisano, a spokesperson for the American Association of Health Plans (AAHP), a national trade organization based in Washington, D.C. Make sure your doctor has all the details of your situation so he or she can present the best case on your behalf. For cases in which your doctor isn't willing to push for you, consider switching doctors within the plan. You can always ask your new doctor at an initial consultation whether he or she is willing to put up a fight for you. Suppose you've been diagnosed with a rare cancer and your HMO sends you to an oncologist on staff. Meanwhile, you learn that a nearby medical center has a doctor who specializes in the type of cancer you have. But when you ask your HMO if you can see that doctor, you get turned down. "Go and see what the doctor [at your own HMO] plans to do," Steinberg says. "Get a written statement." Then go to the expert at the clinic, pay out of pocket and ask him or her to provide a treatment plan. Inform your HMO about the two different plans, and ask your HMO to bring its plan in line with that of the expert (if they differ) or else to send you to the outside physician. If your requests are still denied, consider a formal appeal. "Every managed care plan has an internal appeals process," Pisano says. The AAHP's Code of Conduct advocates a patient's right to a "fair and fast" process of appeal that takes into account the severity of the condition. Be sure you follow your HMO's instructions on how to file an appeal within its deadlines. Look in your coverage book (also called "evidence of coverage"), which includes information on when you are due a response. Members of Kaiser Permanente in Southern California, for instance, should expect a written acknowledgement within five days after they file a written complaint. Members may be asked to appear before a committee to present their case, and the committee must make a decision within 30 days or ask for more time. The details of your HMO's appeals process may differ. Call your customer service department to learn more. For general guidance in composing an appeals letter, consumers can turn to independent organizations like the Health Rights Hotline, a pilot project in Sacramento, California, that posts sample letters on its Web site (http://www.hrh.org). To minimize future problems, keep careful records of all interactions with your HMO. Jot down who said what, the date of the conversation and the person's title and telephone number. Also ask for decisions in writing. Pat Moore, a homemaker in Martinez, California, learned that rule the hard way. When Moore's son needed speech therapy after brain surgery, the HMO sent them to a practitioner 40 miles from their home. When Moore protested having to travel that distance, her HMO approved a local therapist over the phone. After taking her son to the nearby therapist, Moore began getting bills, even though speech therapy was covered under her plan. "I assumed if you did something over the phone, it was a done deal," says Moore, who now knows better. The lesson: Document everything, even when the HMO says "yes."
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