Basile Pappas woke up one day barely able to walk or move his arms. Doctors at a nearby Philadelphia hospital diagnosed the problem as a serious spinal infection that required sophisticated surgery. Lacking the appropriate personnel, the hospital arranged a transfer to the spinal cord trauma unit at Thomas Jefferson University Hospital in Philadelphia. But just before Pappas was put into the ambulance, doctors discovered that Thomas Jefferson wasn't in the network of his health maintenance organization, U.S. Healthcare Inc. It took three hours before Pappas was transferred to a U.S. Healthcare-approved facility. Today, Pappas is confined to a wheelchair. His lawyer, James E. Colleran Sr., argues that the lengthy delay contributed to his paralysis.
Although extreme, Pappas' case illustrates the complications that can arise when a managed-care company's policy is at odds with a doctor's order. Lifesaving or critical treatments may be delayed because the HMO won't approve the provider, as in Pappas' case, or because plan administrators deem a procedure too expensive. "In today's HMO environment, access to care is very much driven by cost containment," says Carol O'Brien, attorney at the American Medical Assn. For that reason, many HMOs restrict access to specialists for chronic illnesses like heart disease and refuse "experimental" treatments, such as bone marrow transplants.
Persuading your HMO to approve expensive, specialized treatment can be a bureaucratic nightmare. Many HMO enrollees may not even know they've been denied care because their doctors don't tell them and they don't ask, says Sue Andersen, associate professor of clinical law at George Washington University Law School. But learning the plan's fundamentals, especially how to appeal a claim, will dramatically improve your chances of receiving all the care that you need.
RESEARCH. If you are considering joining an HMO--or are currently enrolled--you'll want to first get a handle on how much flexibility and access to care the plan actually offers. Although the American Association of Health Plans (AAHP), the managed-care industry's trade organization, encourages its members to provide detailed information, doing some research on your own is recommended. Ask either your employer's benefits administrator or the member services department at your HMO about such topics as the plan's provider network; benefit coverage, including out-of-area and emergency care; the reasons care may be denied; and a description of how plan physicians are paid, including any financial incentives.
For instance, some HMOs give bonuses to primary care doctors, the general practitioners who act as gatekeepers, if they limit their number of patient referrals to costly specialists each month. If your doctor is reluctant to or doesn't explain the payment process clearly, ask your member services department. HMOs in most states aren't legally required to tell patients how doctors are paid, but AAHP members should. Also, "in most plans, doctors' compensation is figured on a variety of factors, including patient satisfaction," says Susan Pisano, AAHP spokesman. A doctor who denies care to a patient who then complains might be docked later.
The first step if you have been denied coverage is to contact your employer's benefits administrator or the HMO's member services department to find out exactly how your plan's appeals process works. Follow the procedure exactly as described because should you decide to pursue the claim to its final end--arbitration or litigation--you'll have to demonstrate that you've exhausted all possible appeals channels.
You may well be able to get some satisfaction from the appeals process. However, "be ready for red tape," advises Lia Royle, a partner at Anderson Kill & Olick, a law firm that specializes in insurance disputes. The AAHP says only that appeals must be resolved "in a timely manner." Most plans have a 30- to 60-day grievance procedure. In practice, an appeal may take a few weeks or several months, depending on the severity of your case. However, an expedited process should be available for emergency situations. Seriously ill Medicare HMO patients, for example, are entitled to a response within 72 hours.
DEFENSES. To make the process easier, learn what the usual course of treatment for your illness is and why. Then, have the HMO put in writing the clinical reasons the claim was denied as well as the names of those involved in the decision. Most important, find out whether or not those people have medical expertise relevant to your problem. If you are a diabetic, for instance, you'll want to have an endocrinologist involved in the decision to review your request. If qualified medical personnel were not involved in your denial, you might want to get a reversal for that reason alone.
Another good defense: credible advocates who can exert influence with your HMO. Start with your physician. Consider the valor of orthopedic surgeon Thomas Trancik. When 29-year-old Wanda Peake came to him in October, 1995, she had fractured her lower tibia so severely that the bone had punctured the skin. Peake's HMO, Healthsource South Carolina Inc., initially denied the doctor's request for corrective surgery for reasons that Trancik and the HMO now dispute. Desperate for more support, Peake's husband enlisted the help of the benefits manager at his company, through which the couple was covered. The company intervened on her behalf, and as a result the HMO reconsidered.
SUPPORT. If neither your doctor nor employer's prodding move your HMO, get a second opinion from an outside source and have that doctor explain his or her reasoning in writing. Obviously, you'll foot the bill. But free information to help bolster your case is available from public advocacy groups such as the American Cancer Society. Present copies of all letters and reports, along with a description of the care you want and why, to your HMO's administrative review board.
Should your HMO dawdle in answering, call your state insurance commissioner and department of health. The numbers are listed in the government section of the phone book. Have in hand thorough records of all letters written, calls made, and decisions reached so that regulators know what ground you've covered. If the state agrees that the decision was inappropriate, it may be able to argue your case with plan administrators, free of cost. Also, be sure to tell your HMO that you've contacted state regulators. Since most commissioners keep records of all consumer grievances, the prospect of a state investigation may spur your HMO into action.
Take the case of one 60-year-old freelance writer who asked not to be identified. When her HMO, Staten Island Medical Group, part of the Health Insurance Plan of Greater New York Inc., delayed approving her request for a cancer specialist, she turned to New York State's Office of Managed Care. Armed with letters from the writer's breast cancer specialist that explained why she needed this specific care, a state employee lobbied the HMO and within six weeks, HIP approved the request.
Litigation is not usually advisable, since it is costly, time-consuming and, in some cases, explicitly forbidden in the plan contract. However, its primary advantage is that, in addition to receiving reimbursement for the cost of care, you may be able to collect damages.
The more common but equally onerous option is to present your case before an independent arbitration committee appointed by the HMO. Arbitration limits your possible reward to either approval for the previously denied treatment or reimbursement, given that you've already gotten care outside the HMO physician-and-hospital network, says GW's Andersen.
Above all, be persistent. Most HMOs have competent and caring doctors. You might have to fight to get to them, but it's a battle that may save your life.