Question...Who really determines medical treatment, the HMO or the doctor?
The scary answer is..both.
Your HMO may tell you that it won't pay for the treatment your doctor has prescribed but will pay for a cheaper alternative, or that they won't pay for a recommended treatment at all because it is not, in their view, "medically necessary".
Is that practicing medicine? The state of Texas thinks so and recently suspended the license of an HMO doctor who worked for United HealthCare and denied payment for respiratory care for a home bound young boy.
It is common in my own practice to recommend a certain course of treatment only to have the patient's HMO say they would only pay for reduced treatment. I've even had HMO doctors tell me they think the patient needed the treatment but should pay for it themselves, even though the contract the HMO has with the patient's employer and with me specifically prohibits such practices. The patient in such a circumstance has only two choices: go forward with the treatment while the lengthy appeals process is undertaken and risk being hit with a big bill if the request is ultimately denied by the HMO, or wait and suffer without treatment while the HMO grinds its wheels.
What can you do?
Be sure you understand exactly what your doctor is recommending and why, and then if the HMO denies the request for payment...COMPLAIN...loudly and longly. Complain to the HMO, your state department of insurance and the state medical board. Don't wait, time is not on your side. Fair or unfair, the squeakiest wheel gets the grease in HMOs, you can win your case and quickly if you make enough noise.
So, the debate will continue. HMOs will claim that they do not make any treatment decisions, only financial ones. But, give me a break, if the HMO refuses to pay, has a contract that says the doctor can't charge you directly, and your doctor can't afford to give away free care and keep his doors open, isn't the HMO really making medical decisions after all?
Thomas A. Grugle, M.D.
c1999
www.cybercouch.com