How to Fight the HMO System, and Maybe Win
You’ve been to the ‘gatekeeper’ doctor at the HMO, and she refuses to make a referral to an orthopedic specialist for that lower back pain that’s bothering you. Aspirin and hot showers aren’t doing the job, and you want the specialist’s opinion.
How do you fight the system? This is where you exercise the right to appeal.
The handling of grievances and appeals is one of the hottest issues in health care today.
‘We want to give assurances to consumers that we get it, we hear what they say. They want fair, fast and effective independent review,’ said Karen Ignagni, president of the American Assn. of Health Plans, the national HMO trade group. The California Assn of Health Plans, the state trade group, has already recommended that its members create independent review systems.
Consumers want a better appeals system because they fear health quality could be compromised by the medical industry’s desire to save money. It is a delicate balance. Employers want to control health insurance spending, so they turn to managed care, which funnels the patients through a gatekeeper system, with the primary-care doctor typically deciding whether someone needs a test or a specialist. Prodded by employers, HMOs are striving to control spending, yet not be so stingy that they enrage their members or the doctors who care for them.
The system has to have some slack, and right now it doesn’t have enough to keep people happy. That’s why the HMO industry is calling on members to adopt independent review as the last step in the appeals process. If the health plans don’t do it voluntarily, Congress might make it compulsory, and add other, more unpalatable provisions, the industry fears.
Meanwhile, customers have to deal with the current complicated system and figure out the best way to have their voices heard.
Be pushy, insistent and persistent, says Carol Jimenez, a Los Alamitos attorney specializing in health coverage issues for consumers.
‘Sometimes it is mind-boggling, the things they try to deny coverage for,’ she said.
Jimenez cites the case of a Southern California woman who collapsed on vacation, suffered a brain aneurysm and was hospitalized for surgery. The HMO said she should be transferred to a hospital in its network for surgery to treat the aneurysm. But the patient’s neurosurgeon and her family refused, arguing that they believed she wasn’t medically stable. The neurosurgeon operated, and when the woman’s condition was stabilized, the family said it was willing to transfer her to the HMO’s network hospital. The woman is now recovering, but the HMO said it is not obligated to pay for the surgery because it was not performed at a network hospital.
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Some general rules recommended by Jimenez, who also serves as counsel for the network of state-funded health care counseling services in California: File any complaints or appeals promptly and in writing. Get the full name and telephone extension of anyone you speak to at the customer services department. Get a copy of the file the HMO is using in considering your case.
In some cases, if the HMO doctor doesn’t support your appeal, you may want to seek a second opinion from a doctor outside your HMO. In all likelihood, you’ll have to pay out-of-pocket for this visit. But if the second doctor disagrees with your HMO doctor--recommending, for example, that you need a test or procedure that the HMO doctor denied--you’ll have some ammunition to help persuade the HMO to reverse its decision.
It’s worth noting, however, that just because you think you need or want a procedure, it doesn’t mean you’re always entitled to it--or that the doctor or HMO that denied it has done you wrong. Doctors and health plans are caught in a squeeze between their responsibility to provide only the care that is necessary and a public that has been conditioned to believe it is entitled to get whatever it wants.
Here are the appeal procedures for some of the biggest players in the California health market. However, keep in mind that some of the details will differ if you are enrolled in an HMO through Medicare or Medi-Cal, or if you are a state or federal employee.
Kaiser: A member can submit a claim or complaint to a service representative at any Kaiser clinic or hospital. Kaiser will send a letter within five days saying that it has received the complaint. It will respond within 30 days to the substance of the complaint. A person who is not satisfied with the answer can make a second-level appeal within 60 days. Kaiser says it will usually respond within 30 days. There is a third appeal procedure, with the results subject to binding arbitration. Contact Kaiser’s member service center at (800) 464-4000, or write Kaiser Foundation Health Plan, Customer Service Call Center, P.O. Box 1840, Corona, CA 91718.
Blue Shield of California: A call to member services begins the appeals process. All denials are reviewed by Blue Shield medical directors who are physicians. The appeal will be answered within 30 days. A second-level appeal will be handled by another physician within the Blue Shield system. There is a third stage of appeal, with the case reviewed by a Blue Shield physician, or an outside expert dealing with the particular medical specialty in the case. Blue Shield plans to change its system this summer to have the third-level appeals handled entirely by independent outside experts. Contact member services at (800) 443-5005 or write Blue Shield Grievance Resolution Department, 6300 Canoga Ave., Woodland Hills, CA 91367.
Health Net: The initial appeal goes to the medical group. A decision by the medical group can be appealed to the health plan itself. A third level of appeal goes to an independent outside expert. Health Net said the entire appeals process will take no more than 30 days. Contact member services at (800) 522-0088 or write Health Net, P.O. Box 10348, Van Nuys, CA 91410.
PacifiCare of California: An appeal goes to the health services department, which reviews the case and answers within 30 days. A second-level appeal goes to a physician review committee, which will hold a hearing within 30 days. The patient can attend the hearing. If not satisfied, she can ask for another review by PacifiCare medical directors. There is a final appeal handled by binding arbitration. Contact member services at (800) 624-8822 or write PacifiCare Appeals Department, P.O. Box 6006, Cypress, CA 90630.
Patients who exhaust the HMO’s appeal process can file a complaint with the California Department of Corporations, the state agency that regulates HMOs. The agency’s consumer complaint number is (800) 400-0815.
Medicare HMOs are distinct. An appeal must be reviewed and answered within 14 days. An expedited appeal is done in 72 hours if the patient has a problem that could seriously jeopardize life or health, or the ability to regain maximum function. If the HMO turns down the first appeal, an individual can ask for a reconsideration, and the health plan must answer within 30 days, or 72 hours for an expedited appeal. If the appeal is rejected again, the HMO must send the case to the Center for Health Dispute Resolution, located at 1 Fishers Road (second floor), Pittsford, NY 14534. The center, which can be reached at (716) 586-1770, is an independent organization.
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Question: Is a dependent who becomes ineligible under a medical plan offered by a parent’s employer because he or she is no longer a student entitled to continued coverage and protection under federal law?
Answer: The COBRA law (Consolidated Omnibus Budget Reconciliation Act) allows a worker to keep health insurance after leaving a job, in return for paying the full cost of coverage plus a maximum 2% administrative fee. The protection for dependents applies in cases of divorce, death of the worker, or cases in which children who were dependents become too old to be covered by the policy. The child can keep the coverage for 36 months after becoming ineligible to stay on the parent’s policy. After the three years of COBRA coverage is used up, another law, HIPAA (Health Insurance Portability and Accountability Act) says companies must make available individual insurance policies. But the HIPAA-related coverage is costly, because people with serious medical problems buy their individual insurance through this program. If your child is healthy, he or she should simply go into the market and look for individual health insurance first before using the COBRA and HIPAA eligibility. Contact several independent insurance brokers to see what’s available.
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Q: My mom is 78 and recently had a stroke affecting short-term memory. She lives in a private board and care home . . . we pay for this out of monthly income, and so far it is affordable. My mother has assets of approximately $100,000 and the equity in her home. . . . My question is whether Mom’s assets are protected if she should need Medi-Cal.
A: Medi-Cal, the state’s name for the state-federal Medicaid program that pays the nursing home bills for the indigent, is complex and often confusing. People must meet an asset test to be eligible for the program. If your mother applies for Medi-Cal, she can protect her house by signing a statement that she intends to return home. Call California Advocates for Nursing Home Reform, (800) 474-1116, to get the number of a qualified elder law attorney. The organization also has helpful publications on nursing home eligibility and financial issues.
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Q: My husband and I are both students and working part time. We have no children and no medical coverage through our employers. Is there a state or county health insurance program for which we’d qualify? Our incomes are too high to qualify for Medi-Cal.
A: It doesn’t look as if there are any programs designed to help you. Check with your schools to see if you can obtain less expensive group coverage as students. Even if you can’t afford insurance, there is a source of free quality care. There are more than 700 health centers with 3,000 sites across the country providing free care, with financial backing from the Bureau of Primary Care, a unit of the federal Health Resources and Services Administration. To find a local health center for you in Turlock, in Stanislaus County, call (800) 400-2742 and ask for a directory, or check the Web site at https://www.bphc.hrsa.dhhs.gov.
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We welcome suggestions, questions and tips about the fast-changing world of health care. Write to Bob Rosenblatt, Health, Los Angeles Times, Times Mirror Square, Los Angeles, CA 90053. Or e-mail to bob.rosenblatt.latimes.com.
