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Health Insurance & Affordable Care Act

Supreme Court Ruling Narrows Suits Against HMOs

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But Palmisano says the ruling points up the need for Congress to pass a "patients' bill of rights," which includes the right to sue your plan. "We're saying that a federal law [is needed] that allows HMOs to be held accountable when they interfere with the patient-physician relationship," Palmisano tells WebMD.

Monday's ruling is limited in that it applies only to those times when a doctor is making a decision both on treatment and eligibility, says Peter Budetti, MD, director of the Institute for Health Services Research and Policy Studies at Northwestern University.

Gregg Bloche, MD, a co-director of the Georgetown/Johns Hopkins program on law and public policy, backed Herdrich's case, but he says he still believes the industry may come up a loser at the end of the day. He says non-ERISA suits involving issues of whether a health plan denied a treatment that a doctor wanted for a patient could fit under the Herdrich ruling.

"The industry may be better protected from the class-action sharks but not from the malpractice minnows in state court," Bloche tells WebMD.

Like Cynthia Herdrich, Jan Greene, a 39-year-old freelance writer from San Francisco, had a bad experience with an HMO. And she has some advice -- short of a lawsuit -- for those who find themselves in the same boat.

Greene and several friends developed an intestinal illness after eating a fresh-raspberry dessert at Greene's bachelorette party. Greene's HMO doctor diagnosed her over the phone with stomach flu. But she contacted her local health department, got tested, and was diagnosed with cyclospora. Armed with that information, she went back to her doctor and got the antibiotics she needed to treat her illness.

Greene, who has since switched to a PPO plan, has these suggestions for people trying to resolve conflicts with a health plan:

  • Find out exactly who makes the decisions for your care; it's usually the insurer or the medical group that is contracted to give care. Call them and push for what you need.
  • If your coverage is provided through your job, consult the human resources department for help. As representatives of your employer, they have more clout because they help decide which insurer to use.
  • Ask a human resources representative for shortcuts. They may know the name of someone you can call directly to discuss the problem, so you don't waste time being transferred from person to person.

Many medical centers and some managed-care organizations have patient advocates who can also assist patients and their family members in getting the care that they need, and getting providers who are able and willing to provide that care.

 

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