Introduction

Reviews

Getting Good Care in an HMO—Part 2

Timothy B. McCall, M.D.

The secret of getting good care in an HMO is learning how to be an assertive and effective consumer. Read on for more tips, including how to appeal when you health plan says no, in the second of this three part series…

• Learn the system. HMOs have different rules and regulations, different services they will pay for, different services they deny. People who know the services they’re entitled to are more likely to get them. Study the brochures before you join, remembering that advertisements only stress a plan’s advantages. After you join, read the member handbook to get to know the ins and outs of your plan. Glance through the newsletters and other material they mail out for updates and changes in their policies. When you go for visits, ask the nurses and doctors or other members you bump into in the waiting room how to work the system to your benefit.
• Find out how the doctors are paid. HMOs pay some doctors a salary, Consider a Point-of-Service (POS) option if you can afford it. For an additional fee many managed care plans offer the option of consulting doctors outside of their network. Consider the woman who is generally satisfied with her primary care doctor, who nonetheless gets her gynecologic care from an outside doctor she's known for years. A POS option also makes sense for people who may want to get second opinions from doctors not affiliated with their plan or for those who feel a particular concern isn’t being addressed adequately by their HMO. In the case of an appeal, the opinion of an outside physician--preferably in writing--backing up your contention that you need a denied service can be useful ammunition.
• Be assertive and persistent. The squeaky wheel gets the grease is the number one survival rule in an HMO. If there is a service that you feel you are being unjustly denied, tell your primary care doctor. It’s hard for doctors to say no to patients who can make a good case for why something is necessary. Sometimes it’s possible to work out deals with your doctor. If you’re told you can’t see a specialist now, what about in 3 months if your symptoms persist?
• Appeal Denials of Needed Care. Sometimes, your doctor may not be the problem. In some HMOs, a doctor can’t even order an expensive test or service without getting approval of the plan’s administrators. Some plans even forbid doctors to tell you about useful treatment options that the plan doesn't cover. If it’s the HMO’s policy--and not your doctor--that’s the roadblock, you’ll have to take the problem up the chain of command. If you have no luck with the plan’s administrators, you may have to file a grievance. Although it sometimes isn’t advertised to members, all HMOs have formal grievance procedures.

It may take multiple phone calls and letters but, if your appeal is justified, persistence often pays off. HMOs count on the fact that if they say no often enough, most people will give up and either pay for the service out-of-pocket or simply forget about it. By the way, be sure to keep copies of all your correspondence with your HMO. Important letters should be sent by registered mail.

One helpful tactic is to CC copies of your complaint letters to your state’s insurance commission or department of health. Another is to interest a local consumer reporter in your case. Bad publicity may be even worse for the HMO’s bottom line than paying for the service you’re requesting.

Remember, HMOs are businesses. Ultimately, their survival depends on satisfying their customers. One particularly effective technique is to complain to your employer as well as to the HMO. Since HMOs stand to lose millions if a large company drops them the following year, an employer's appeal may get their attention better than anything you as an individual can do. Even one person, however, is far from powerless.

Arthur L. Caplan, a professor at the University of Pennsylvania, attended a board meeting of a large Minneapolis HMO where the subject was enrollee appeals of service denials. The questions the board members asked, he said, "were not 'How much does it cost?' or 'Will it work?' but rather 'Does the person have a lawyer?', 'Are they likely to be in touch with the media?', 'Is this someone who's going to be persistent or just go away?' and 'Can they make trouble for us in the community?'"

Next: Getting Good Care From an HMO, part 3

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