TODAY's newspaper carried the story of a woman who'd paid into the HMO for thirty years, over 140, 5k a year, and then, as she lay dying, they wouldn't give her a nurse. Her daughter worked --couldn't do it.. The HMO said "you pay the first month, then we'll pay". The daughter fought --saying that Mom had thirty days to live. Didn't win. Mom died with no care at all.
I personally know two people who were denied services that they had paid for ---causing a child to become a vegetable instead of giving a simple brain concussion test... the HMO declared they'd capped out, or capitated. THE HORRORS OF CAPITATION.
Then the child's father a decade later gets CANCER of the stomach and the HMO says 'well you can only have one test a month.' And we must delay curing you until we've done more tests." Meanwhile cancer is growing.
Challenging your HMO can be like
going to war. Be prepared.
By KELLEY BOUCHARD and MARY K. FITCH
You can do almost everything right. You can pick the best primary-care physician, find the right HMO and plan for the worst possible case.
But when it comes right down to it, sometimes you have to fight for what you want in the managed care system.
That's the lesson Allison Lobdell learned a few years ago. The Boxford woman was trying to get pregnant for months when she suddenly developed excruciating abdominal pain and vaginal bleeding.
First it took her several phone calls and nearly four hours just to schedule an appointment with her primary-care physician. Then, because her doctor was away, she had to see a nurse practitioner, who diagnosed that she had a ruptured ovarian cyst and told her everything would be OK in a few days.
When the problem persisted four more days, Lobdell got scared. After several conversations with the doctor's secretary, Lobdell demanded that she be referred to a specialist, a gynecologist.
Late that afternoon, after nine days of pain and bleeding, Lobdell got her referral. It turned out she had an ectopic pregnancy that could have ruptured her Fallopian tube and killed her.
"I'm very trusting and my trust was completely violated," recalls Lobdell, now 38 and a mother of three. "Sometimes you really have to be a stinkpot to get anything."
To add insult to injury, her HMO a few days later mailed her "An Expectant Parent's Guide," a pamphlet with a letter that began, "So you're having a baby...!"
Lobdell's case shows just how trying and impersonal the managed care system can be. While HMOs claim high satisfaction rates, critics say most people don't find out how tough it can be to get the care they need until they face a medical crisis.
HMO members need a good battle plan and sometimes must fight to get the care they want, whether or not it's covered by their health plan.
It may mean standing your ground when your doctor refuses to give you the referral you want. Or you may have to wrangle with an HMO bureaucrat on the phone for hours until a medical director is called in to review your case. In more dire situations, you may have to file a complaint with the state attorney general's office to get some action.
Regardless of the circumstances, it's clear that those who complain the loudest often get the care they want.
"The biggest thing that people need to know is, if something gets turned down, or it's not working out, you can't just be quiet. You need to speak up, because the person who makes the most noise gets the care they need," says Rebecca Derby, a policy associate with Health Care For All, a statewide advocacy group.
HMOs say giving in to such demands shows they are responsive to their members. But others say people shouldn't have to beg for health coverage they deserve.
However, because HMOs are set up to save money and limit benefits, doctors say members can no longer expect health care on demand. Some expensive and experimental procedures, tests and services simply aren't covered and often aren't considered medically necessary.
The trouble is, it's tough for average folks to figure out what their HMO covers. Benefits are usually spelled out in a subscriber agreement or an evidence-of-coverage booklet, but these can often be difficult to understand.
"The HMOs hire lawyers to write these plans to give them total latitude in what they have responsibility to do," says state Sen. Frederick Berry of Peabody. "It's there in black and white, but they're trying to maintain the advantage."
HMOs acknowledge there are flaws in the system. They also admit they sometimes cave under pressure from members who fight for what they want. They say that's why they have customer service representatives, medical directors and appeal boards to review complaints. But be prepared for a battle because HMOs aren't set up to give in easily.
"In fairness, we shouldn't provide something to someone who yells louder
if it's not covered in their plan," says Dr. Joseph Dorsey, corporate medical
director of Harvard Pilgrim Health Care.
Initiating the fight
If you're willing to put up a stink, you're liable to get your own way. That's how it was for Margaret Martone, an 85-year-old Lynnfield woman who recently had to fight to get a physical from her new primary-care physician.
He balked because she recently had a checkup with her previous doctor. He said she only needed a complete physical once every three to five years. Eventually, she wore him down and got her exam.
"I told him I came for a physical and that's what I want," says Martone. "If I'm paying for this insurance, why do I have to beg for it? For them it's managed care, but as far as I'm concerned, I'm still paying for the premiums and I expect to get the care I pay for."
It's one thing when you're dealing with a doctor face to face. But in some cases, you may have to fight faceless HMO bureaucrats by telephone.
That's the lesson one 26-year-old Newburyport woman learned. Last December she awoke late one night with a violent headache. Her boyfriend drove her to the emergency room, stopping frequently to let her vomit beside the car. She was so sick her roommate thought she was having a brain aneurysm.
After she was diagnosed with a severe migraine, the HMO refused to pay the $84 bill because her visit was considered not worthy of emergency care. She plans to bring her case to the HMO's appeals board.
"It's just scary," the woman says. "You wonder how bad it's got to be before they cover an emergency room visit."
Her situation raises some tough questions, especially if you can't afford to pay for ER visits out of your own pocket. How do you know when you're sick enough to go to the ER? Should you wait and make sure you're really sick? What if that chest pain you're feeling is just really bad heartburn?
Critics of HMOs say a significant danger of managed care is the tendency to delay care. Sometimes that happens when patients aren't sure a particular treatment will be covered. Other delays occur because an HMO initially refuses to give the go-ahead for more expensive tests or procedures.
"As long as you're well, you're fine. But if you have an acute problem and you can't get help right away, delays can lead to more serious health problems," says Barbara Anthony, chief of the attorney general's Consumer Protection Division.
That's when the AG's office usually steps in. In the last few years, the state agency has resolved about 300 complaints it received against HMOs.
In one case, a couple needed a particular specialist for their sick child, but their health plan wouldn't pay because the doctor was outside the HMO network. The AG's office intervened and within two days the HMO agreed to cover the specialist's care.
In another case, a woman's HMO would cover the cost of a bone marrow transplant but not the $20,000 search for a donor. The AG's office forced the HMO to cover the whole tab and is trying to change how similar cases will be handled in the future.
"If you can't find the donor, paying for the transplant is an illusory benefit," Anthony says. "We're now surveying HMOs to make sure their bone marrow search policy is in line with their transplant policy."
HMOs caving in
Even when policy language is relatively clear in saying a particular benefit isn't covered, HMOs have been known to give in when members put up a fight. That's what Regina Whitehead learned when she recently tangled with her HMO.
In February Whitehead slipped on ice outside her Reading home and smashed both wrists into the frozen pavement. The spill left her with a cast on each arm and a 4-month-old baby to care for.
Whitehead figured her Tufts Associated Health Plan would pay for a home-health aide to help her bathe and brush her teeth each day. But when she called Tufts, she learned that her plan didn't cover an aide unless she also needed skilled nursing care to give her medication or change bandages, which she didn't need.
After arguing for a half-hour with a customer service representative, Whitehead lost her cool and threatened to call the media about her situation.
"I was feeling pretty desperate at that point, so I actually began to scream and cry," recalls Whitehead, 34. "I told her, 'I'm not going to rest until you rue the day you ever heard the name Regina Whitehead.'"
A Tufts medical director was brought in on the case and eventually agreed
to cover a home-health aide for one hour per day during the seven
weeks of Whitehead's recovery.
(THAT IS NO WIN!)
Tufts CEO Harris Berman, M.D., says Whitehead was lucky she got an
aide because it wasn't covered by her health plan. Even with her extenuating
circumstances, an aide wasn't a medical necessity.
Furthermore, Berman points out, traditional indemnity plans, such as Blue Cross/Blue Shield, wouldn't cover an aide in her predicament either.
"No plan would cover that," says Berman. "That's what family and friends are for. Her type of problem is something you go to your minister for. That's a social service and we're not a social-service agency."
Whitehead doesn't see it that way. She got help from friends and family, including her mother, who lives in Manchester-by-the-Sea. But there was only so much they could do.
"The whole point of health insurance is to be there when the unexpected happens," Whitehead says. "You pay all this money over so many years, you'd think when they finally lose the bet, they'd have a little more grace in paying up."
OTHER BATTLES on the internet: http://www.usnews.com/money/personal-finance/retirement/articles/2009/03/16/8-tips-for-paying-for-health-care-in-retirement/comments/
PUT THIS IN GOOGLE "HMO refused to pay" + After years of paying in and
you'll get 4,200 stories!
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