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.
