Sunday, 27 March 2011 20:21

Outsmart Your HMO

Written by  Sandra Gordon
Rate this item
(0 votes)
Outsmart Your HMO Michael Jung - Fotolia

Today, more than two thirds of Americans are enrolled in some form of managed health care. And when the name of the game is cost containment, "quality care" can be tough to get. The squeeze starts with the insurance companies, which are forcing affiliated physicians to see more patients in less time--in some cases, a new patient every seven minutes, while rationing resources such as lab and diagnostic tests. And many managed care doctors are “encouraged” to follow clinical practice guidelines (CPGs), written procedures designed to treat particular diseases for the least amount of money.

HMO doctors can recommend treatment not outlined in the CPGs, and they can spend more time with you during office visits. They can even prescribe brand-name drugs and they can order costly diagnostic tests if they feel you need them. But HMO doctors can't do this for everybody. You have to make yourself stand out.

With this in mind, here's what you can do to increase your chances of receiving the highest-quality service in today's managed-care climate.


Be sure that you pick an HMO that has been awarded a full three-year accreditation status from the National Committee for Quality Assurance (NCQA). This award of three-year accreditation is the NCQA's highest distinction for managed-care organizations who demonstrate excellent programs that promote continuous quality improvement.

Know Your Health Plan. Learn as much as you can about your coverage. “You’re in a better position to navigate the system when you have better information,” says Nick Newsad, a senior analyst at a surgery center in Broomfield, Colorado and author of The Medical Bill Survival Guide ( Go to your health insurance carrier’s Website and log into its insurance portal with your health insurance card number. There you’ll find your benefit plan, including a list of in-network providers, your deductibles, co-insurance, and co-payments. These tools can help you estimate the cost of your treatment. If you’re not sure about something, call your health insurance company and ask. Get the name of the person you speak to and the date of your conversation in case there’s an issue later.

At your health insurance portal, you’ll also get access to your explanation of benefits (EOB). They’re the documents your insurance company sends your provider, telling them what they were paid and what to bill you. “The bill you get from your provider might not match your EOB. If you get billed for more than you should have, you can ask your insurance company to contact your provider about the discrepancy,” Newsad says.


When selecting your primary care physician (PCP), keep in mind that "board certified" (which means that the doctor has passed the Board exam) is better than "board eligible" (the doctor hasn't yet taken this important accreditation test). But even the most credentialed PCP might not be right for you. "Choosing a doctor involves a gut response that starts when you call for an appointment," says James Kvale, MD, professor of family and community medicine at the University of Texas-Houston Medical Center. Clues you're in good hands: The doctor's staff is professional and concerned about your wellbeing. The doctor's office is clean. Your waiting room time is rarely more than 30 minutes. Your doctor listens to your concerns and answers your questions.


Referrals to specialists are usually authorized by your primary care doctor. But if you want to go to a particular specialist your doctor doesn't know and, for some reason, doesn't want you to see, you can get around it by working backward. Call the specialist and tell her you're interested in becoming her patient, and ask if she has a relationship with other PCPs in your plan. (Offer to fax her the list from your HMO's physician directory.) Then switch to the PCP she suggests. (You can always switch back later.)


If you believe that you are not receiving satisfactory care and your physician isn't being helpful, call your HMO's member services department. In many cases, they can help you get the benefit you need. Or you might want to work through the human resources department at your job. You might also consider filing a formal grievance with your HMO (check in your member handbook for the grievance process). Or send a letter directly to the HMO's medical director and the head of its member services department. Ask them to respond to you within a specified time, and tell them you'll seek regulatory or legal help if necessary. If the problem isn't resolved, you can ultimately file a grievance with your state's HMO regulatory agency. Call your HMO's member services department for this agency's address and telephone number. Remember, it's the squeaky wheel that gets the grease.


If you receive a bill from your doctor for a covered service because your HMO hasn't paid the doctor on time, send the invoice back to your doctor. Include the note, "I'm not responsible for this bill. I'm covered by managed care," advises Harvey Wachsman, JD, MD, an attorney in Great Neck, New York, who specializes in managed care. When your HMO fails to pay your doctor, says Wachsman, it's breaching its contract with the doctor. "Let the doctor go after the HMO," Wachsman advises.


Is this covered?" and "What is this going to cost?" are two relevant questions to ask your doctor, who may recommend a treatment that's not covered by your HMO. If your doctor isn't sure about your coverage, double-check your managed-care contract before consenting to any procedures.


To understand your condition and become a decision-maker in your own health care, do your own research online. By being more informed, "you may get better care and you'll feel more in control," says Kvale. If you discover a new treatment your doctor hasn't recommended, there's a good chance it's not yet covered by your HMO. But that doesn't mean it can't be.

Armed with information you provide, your doctor may be able to persuade the HMO to authorize the treatment.


When speaking with HMO customer service representatives, be sure to jot down the date of your call and the name of the representative you speak with. If there's a discrepancy at some point later on, your notes (as in "On April 28 I spoke with representative Jane Doe, who told me this service was covered") may help to resolve the matter in your favor.


If your claim is denied because the treatment you received was deemed "not a covered service," "not medically necessary" or generally "unauthorized," ask your doctor to write a letter to the HMO requesting to have the claim reconsidered. Or call your plan's member services department for an explanation. (HMOs have been known to sometimes reverse their determinations.

They've also been known to make mistakes, so it's always worth asking.) If your

HMO refuses to reconsider, file a formal appeal. Check your member handbook for the appeal process. Do research to back up arguments about your care. It's up to you to look out for yourself.

Last modified on Wednesday, 30 May 2012 15:39

Leave a comment