Tips for Health-Care Consumers
Jamie Court, director of the Santa Monica-based Consumers for Quality Care, a health care watchdog group, offers these tips on dealing with an HMO: % Understand that employers prepay HMOs a fixed, monthly amount for every patient under the HMO’s care, whether or not treatment is provided. In turn, most HMOs pay doctors and hospitals a fixed pool of money for their patients, regardless of how much the treatment costs. The less care a patient receives, the more the HMO, doctor and hospital profit. Under this profit-driven system, patients must protect themselves to ensure that they receive high quality health care.
* Write everything down. Bring a notepad and pencil to all medical facilities and take notes on what your doctor tells you. This will help to keep track of your care, catch any errors and provide a record should there be a question of inappropriate treatment.
* If you are denied care, ask for the decision in writing. You will need a record of the denial if you want to dispute it. Memorialize in written correspondence all conversations if it becomes apparent that you are not receiving cooperation.
* Appeal a treatment denial to regulators. HMOs are regulated by the California Department of Corporations, which has a consumer complaint hotline: (800) 400-0815. In a nonemergency situation, a patient must first request treatment in writing from his or her HMO. If the HMO does not respond in 60 days or denies the request, the patient can then lodge a complaint with the state. In an emergency case, a complaint can be filed immediately with the department. Also, Medicare and Medi-Cal recipients can take a complaint to the federal Health Care Financing Administration. Seeking the help of an attorney at this stage may also be appropriate.
* Find allies in the medical profession. When medical experts advocate care, HMOs find it harder to deny treatment. Insist on a second or third opinion from a qualified professional outside the HMO network. If your HMO won’t pay for a second opinion, pay out of your own pocket. It could save your life.
* Ask how your doctor is paid. Medicare recipients are entitled to see a summary of their physician’s contract with the HMO, which details any financial incentives to withhold treatment. File a complaint with California’s medical board if you believe your doctor is withholding treatment for his or her own pecuniary gain. (800) 633-2322.
* Never take no for an answer. Always ask if there are treatment options available other than those the HMO recommends. Enlist the help of your employer’s personnel department if you get your health care through your job.
