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Below are tips for getting your HMO to change a "No" to your request
for coverage to a "Yes".
Be insistent; be persistent.
Insistence and persistence are the key. Patients should not take "no" for
Treat an emergency like an
If it's urgent, insist on immediate attention. Don't be afraid to demand
the care you deserve. Strange as it may seem, many people understate the
extent of their illnesses and injuries.
Get help from the people who know how to make HMO claims and who are on your
side. These include your employee benefits administrator, the people in your
doctor's office or on the hospital's staff who usually know about making
claims. They will frequently help patients with getting treatments and getting
Get it in writing.
Contact the HMO, by letter if possible, and ask for a letter stating (a)
the medical reasons your claim was denied, (b) the names of those involved
in the decision to deny the claim, and (c) whether those individuals have
clinical expertise in the area of medicine relevant to your problem. For
example, if you are diabetic, ask if an endocrinologist was involved in the
decision to deny your claim. Often, claims decisions are made by physicians
without experience in the field relevant to patients' illness/injuries.
Follow the appeals process.
Find out how your plan's appeals process works: Contact your employer's benefits
administrator or the HMO itself. Read the HMO contract.
If your case is not an emergency, demand reevaluation by the HMO's administrative
review board. Follow the appeals procedures exactly. If you decide to pursue
your claim to its final end -- arbitration or litigation -- you'll have to
be able to show that you've exhausted all possible appeals channels.
Most policies have a 30 or 60 day grievance review procedure. An expedited
review should be provided if necessary. For example, seriously ill Medicare
HMO patients are entitled to a response within 72 hours.
Get doctors on your side.
Have your doctor write to the HMO explaining the reasons your claim should
be allowed. Get a second opinion or obtain the names of other doctors
recommending the kind of treatment you need. Ask these physicians to write
to your HMO on your behalf. Contact public advocacy groups such as the American
Be prepared for red tape.
Your HMO will probably have created its own version of the "facts" relating
to the denial of your claim. Make sure that you have something other than
just your recollection to back up your version of events. Write letters whenever
possible. Keep all medical bills and correspondence with the HMO. Take notes
of all phone calls with the HMO -- the date of the call, the amount of time
you spent on "hold", the name of the person to whom you spoke, what you said
and what was said to you. If you have time, write a letter to the HMO summarizing
the call. HMO's are experts at red tape -- beat them at their own game.
Call and write your state insurance department and department of health --
and let the HMO know you're doing it. HMO's frequently behave better when
they know state regulators are looking over their shoulders, particularly
since many state regulatory bodies keep a record of every consumer complaint
If you're really annoyed, or it's really serious, write to your legislative
representatives -- your state representative or senator, for example. They
know that effective constituent service means votes. Again, send the HMO
a copy of the letter.
Use lawyers with caution.
Think twice before hiring a lawyer. First, few claims involve enough money
to be financially attractive to lawyers. Second, when a patient's lawyer
gets involved, the HMO stops dealing with the patient and communicates only
with the lawyer. As a result, if you do hire a lawyer it's usually better
for the lawyer to stay in the background.
No-fee legal services are often available for those who cannot afford a lawyer.
To find such a lawyer, contact advocacy groups for your particular illness
or injury (such as the American Cancer Society) and the local bar association.
Alternatively, consider filing a claim by yourself in small claims court.
You won't need a lawyer, and the court will provide assistance in preparing
Be insistent; be persistent.
For further information, contact Lia Royle, a partner in the firm's Washington,
D.C. office, phone (202)728-3102
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