A Few Thoughts on HMO Coverage Problems

[Guest guest]

Dear HMO ladies:

Just a couple of thoughts, but . . .

One thing I haven’t seen mentioned here lately is the fact that many – not

all, but many – of us – have the opportunity to CHANGE our insurance/medical

coverage at least once a year. Those ladies who are having trouble with

their HMO’s might consider doing that at the next opportunity (check your

plan – mine for instance allows me to change at ANY time as long as I’ve

been on the current coverage for at least 12 months). If you could stay

under a different system for a year – one which would give better coverage

for the treatment you’re seeking – it would likely be well worth the added

fees for other medical services for that year.

Perhaps some of you could figure out which of the other plans available to

you would give you better coverage for the doctors you wish to see. Then,

spend the time between now and your switch date getting yourself lined up

with those new docs – if possible pay out of your own pocket for the initial

consultations BEFORE you switch & try to get as much of the diagnostic work

as possible done in the cheaper system (quite possibly the HMO). In other

words, be ready to move as soon as your coverage is switched.

And, don’t forget to let your HMO know why you’re leaving when you do. Even

HMO’s have egos – and can be swayed if ENOUGH people SPEAK OUT

appropriately.

* * * *

I have also known people who have paid for outside consultations and gotten

WRITTEN opinions recommending alternative treatment. Bringing that sort of

written documentation back into an HMO can make it harder for them to deny

you. – I suspect because they become worried about being responsible for

things going wrong when you had a written recommendation from an outside

M.D. to do something else & they knew it beforehand! – They seem to be more

reluctant to deny another doc – even an outside doc, than they are to deny a

patient.

Also most HMO’s have some sort of an ombudsman – or customer service dept or

something, and sometimes those folks can help you get connected with a doc

inside the system who is more likely to see things your way. They can also

be very helpful once you have that outside written recommendation – present

it to them as well as to your docs. So, don’t be afraid to use these

services within your HMO.

Best,

Pat

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