When Care is Denied : Bureaucracy and cost controls are the culprits that Californians typically blame when HMOs deny them medical care. Here are two patients’ story: : ROBERT C. COHEN / Battling the System

Occasionally, a feisty consumer will go to great lengths to fight the system.

Robert C. Cohen, who runs Intech Summit Group, a San Diego health care consulting firm, says he lost 21 days of work--and an estimated $22,000 in business income--because his three-year treatment program of allergy shots was disrupted after he switched last year to PacifiCare.

Under the coverage provided through his wife’s employer, Cohen says his primary are physician pulled him off the final year’s worth of shots. His painful sinus infections returned in January, he says, sometimes forcing him to stay in bed.

In frustration, Cohen appealed to PacifiCare in March. “I blame having to start over on my shots, loss of work and the pain of another three to four years of shots directly to the cost-saving procedures you have in place,” Cohen wrote. He also sent letters of complaint to his physician; the state Department of Corporations, which regulates HMOs; the National Committee of Quality Assurance, which accredits HMOs; the American Medical Assn., and even President Clinton.

In April, Cohen says, a Department of Corporations official responded, saying the agency had contacted PacifiCare and been told his problem had been resolved. That same day, Cohen says, his primary care doctor’s office called to say PacifiCare had OKd his referral to an allergist.

That doctor recommended a CAT scan of his sinuses and an allergy test, he says--steps that were approved with another trip to his primary care physician. The allergy test was negative, according to Cohen, though the CAT scan indicated swelling in his sinuses, probably caused by allergies.

In mid-July, PacifiCare OKd an appointment with another allergist; that doctor indicated that the earlier allergy test was invalid and should be repeated, Cohen says. As of last week, he was waiting for appointments for more allergy tests. And he was hoping PacifiCare would allow him to start routine shots again.

“They wear the patient out with all the administrative work,” Cohen says of HMOs in general.

Ben Singer, a PacifiCare spokesman, says Cohen appears to be approaching managed care as if it were traditional insurance.

“He is used to operating in the old fee-for-service medicine, where he went to a doctor whenever he wanted to see the doctor,” Singer says. “With an HMO, it’s different, because the family physician is supposed to quarterback all this.”

Singer says Cohen’s situation illustrates that HMO customers should be prepared to press for reviews of care denials through their plan’s member services department.

“Take good notes,” Singer says. “Be a good consumer. You’ve got to be these days.”