HMOs And Treatment Denial
What if my HMO denies me treatment?
If your Health Maintenance Organisation (HMO) denies you treatment, you've got to enlist the best arsenal of experts you have. So, if it's a bone marrow transplant, you want the best bone marrow transplant expert in the world who's going to treat you to write a letter of advocacy, of why this is medically necessary, why your life depends on it, why you have a short window of opportunity, and why you can't wait three or four months to go through some appeal process. So you have to address the urgency issues right away. The more urgent and the more emergent the procedure is, the most likely you're going to get quicker review, and a quicker look at it. If it's something that is not urgent or emergent, they're going to generally call it not medically necessary and delay as long as you can. So you need to use the doctors and anyone else you have in your treatment system to help define it as urgent and emergent as best you can.
What if my HMO refuses to cover a treatment because it is 'experimental' or 'investigative'?
If your HMO denies you something under a catchall phrase of 'investigational' or 'experimental', you have to get the booklet and see what the definition is. Companies are using all kinds of different definitions. Enlist your medical team of experts to look at that definition. In many cases, if your life depends on it, that's when you may need to – at last resort – consult with a lawyer who specializes in investigative or experimental denials.
What if my HMO denies me access to a treatment facility?
If you're denied access to a specific facility by your HMO, such as your chosen hospital that you want to go to, you need to look in your contract because your contract may say that your HMO can send you to a place and you don't have a choice. That's when you try to get on the phone with the medical director and you need to argue why the facility you want is medically better or superior and medically necessary. You have to make some very tough arguments because they can, in that insurance contract, put you in a zoo. In that zoo, there are various cages that you must remain in, and to get out of the zoo or get out of the cage, often can cost you a lot of money. So you want to make sure that you have an argument as to why you need that and not just because it's a prettier place or that your grandma went there. You need strong arguments from doctors as to why they're more capable at that facility.
What if my HMO won't allow me to see a specific physician?
If your HMO denies you the ability to see a specific physician, a world renowned expert or someone that you just have the most confidence in, you have to look in your contract to see if you're in one of those closed networks. If it says you're in a closed network and it won't pay for anyone outside of the network, then you argue or use your best argument to suggest that the person they're providing you is not an expert in your disease. The person does not have the knowledge, skill, background, or experience to fight your disease and therefore you need to go outside the network to see the person. You need to argue why that person is someone you have to see versus someone they want to provide you with that you don't want to see.
Does my HMO have to grant me an appeal?
The HMO's are required to grant you an appeal under Federal and most State laws. The HMO's appeal process can work for you on small items or things that are just misunderstood. Some of them require you to go through that. You don't ever want to be lost in the appeal process while you are dying because of some undiagnosed diseases, so you want to try to get that procedure, get that treatment, and get that specialty visit and then fight the appeal later.
What steps should I take if my HMO denies me treatment?
If your HMO denies you treatment, you have to ask yourself: does my life depend on this? If your life depends on it, then you need to take them on with the use of your doctor immediately, consider hiring an attorney and then do anything and everything necessary to get second opinions to make sure that both of your first answers are correct, that you're with the right doctor and that it is emergent and that you need it right away. If it denies you smaller matters, smaller dollar matters, then you take on as much self help as you can. You try to write them letters and start with the CEO and the medical director. We suggest to people that in those type of denials that you Federal Express the letters there. It rises to a different level if your letter comes in a Federal Express package. We also suggest to people that they make it very short. One paragraph as to who you are and how you got your insurance. One paragraph as to the problem and one paragraph as to what the solution is. The letter in three to four paragraphs written factually, graciously, with a time frame at the bottom, in a Fed Ex package gets a lot of attention.
What kind of documentation should I keep relating to my HMO's denials?
Relating to your HMO denials, you should keep anything the insurance company sends you, and a copy of your insurance contract, and obviously anything you send to them. You should also keep a log of anybody you talk to on their 1-800 line, any of their people who are discussing what's covered and what's not covered, because in many cases we've found out that those people who are on the phone telling you something's not covered, have never seen your contract, and have never had training in denial of or approval of anything, and are generally doing what their supervisor is saying is cheapest.
Why is keeping a log of people I talk to at my HMO so important?
In dealing with the HMO, it's really important that you get the name of the person on that 1-800 number, and then ask for supervisors and keep their names, and get as many numbers. A lot of these HMOs use a fictitious person. When you're talking to Sally Brown, you're talking to someone who's denied your claim and they don't ever want to put their own name behind it, so you will get a different voice but it might have the same name. So it's important - get the names and get a number to call them back at. Most of them can't receive calls, they can only make calls, so that's another thing that down the line looks as if they're playing games with you if you need to fight them.