Patient Peacemaker : Doctor Helps Consumers Solve HMO Disputes

With membership in managed-care plans continuing to soar, some consumers are finding it difficult to navigate the system, especially when something goes seriously wrong.

Unless you are poor or elderly, it’s not easy to get help. Enter American Medical Consumers, one of the more unusual businesses to spring forth from the managed-care industry’s growth. The company was founded by Vincent Riccardi, a pediatrician, geneticist and self-described “personal medical advocate,” who operates the business from his hillside home in La Crescenta.

Riccardi, putting to use experience gained as a consultant for managed-care firms, dispenses advice and assistance to people at odds with their doctors or health plans. For example: how to select a health plan or medical group, or how to dispute a denial for a referral to a specialist. (The advice isn’t free: He charges $50 to $135, depending on how sticky the problem is.)

Riccardi believes that the spread of managed care has dramatically affected relationships between doctors and patients.

“The doctors have essentially abandoned patients in terms of advocacy,” says Riccardi, 56. “Doctors have been put in a conflict between taking care of all of their patients’ needs or looking after their own financial needs.”

Riccardi says these conflicts have created the need for organizations that can negotiate on the patient’s behalf.

Susan Simon, a spokeswoman for PacifiCare Health Systems, an Orange County-based HMO, agrees that members “not steeped in the system” can encounter problems related to medical plan benefits or rules.

“We think members can use more education,” she says, noting that the HMO is working with a Northern California consumer group to publish a brochure about how managed care works.

She encourages members who experience problems with their doctors or medical group to contact the health plan’s customer service department or, if that fails, go through the formal complaint process that HMOs are required to provide.

Jeanne Finberg, an attorney specializing in health-care issues for Consumers Union in San Francisco, says that for some consumers, there are other alternatives to a service like Riccardi’s.

Low-income patients who belong to managed-care plans can consult Legal Aid attorneys to resolve disputes, while people enrolled in Medicare HMOs can seek help from the California Department of Aging’s Health Insurance Counseling and Advocacy Program.

“But there really isn’t much assistance available for most consumers” with private insurance, Finberg said. “The health plans don’t make it easy for you to know how to contest a decision or how to get more information about things.”

Riccardi says many of the 500 phone calls he has logged since early last year are from patients who have made some initial attempts to resolve their disputes.

Though Riccardi--a consultant to a California HMO on physician credentialing issues--is critical of some managed-care policies, he is careful to note that American Medical Consumers is “not an HMO-bashing organization. It’s about how we can work together in the system.”

The aim of American Medical Consumers is to help people resolve disputes amicably, without getting lawyers involved, Riccardi says.

The complaints he hears most frequently involve delays or denials of referrals to specialists and patients’ doubts about the qualifications or appropriateness of specialists assigned to perform surgeries and other procedures. Another common complaint is about health plan restrictions on which medications doctors can prescribe.

Times staff writer David Olmos can be reached by e-mail at david.olmos@latimes.com or by fax at (213) 237-7837.