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Patients Take on HMOs -- and Win

Appeals to HMOs Successful Half the Time

WebMD Health News

Feb. 18, 2003 -- It can be one of the most frustrating experiences at a doctor's office. You believe that you need a particular test, only to find out that your insurance doesn't cover it. Now, a new study chronicles what happens when patients take on their HMOs.

A few patients are dissatisfied enough to take their complaints to their insurance company's internal review board. A new study published in the Feb. 19 issue of TheJournal of the American Medical Association delves into the nature of those cases and how often the patient wins them. It turned up some revealing trends.

Researchers at the Harvard School of Public Health considered more than 3,500 appeals brought forward between January 1998 and June 2000 at two California HMOs, separating most appeals into three broad categories. About a third included questions of medical necessity, another third had to do with disagreements over the scope of benefits covered by insurance, and 20% were disputes about healthcare providers outside of the network of approved providers.

Medical necessity is a common gray area, but about 40% of cases fell into five categories: surgery for obesity or obesity-related conditions, breast alterations, varicose vein removal, bone density and sleep studies, and treatments of scars or benign lesions.

Study researcher David Studdert, PhD, says that the problem lies in what is considered medically necessary. "We have to make decisions about whether these things are reasonable to cover with health insurance or not. If the answer is yes, we ought to be real explicit about that, because consumers deserve to know," he tells WebMD.

"The definition of medical necessity varies, but what you're really asking is ... would a reasonable health professional with relevant training and knowledge support the medical intervention?" Sara Rosenbaum, JD, professor of health law and policy the George Washington University School of Public Health, tells WebMD. Of course, reasonable people will differ, and that means that disputes about medical necessity are likely to remain a fixture of HMOs.

More than 60% of disagreements about the scope of benefits involved one of seven categories: foot orthotics, speech therapy, physical therapy, dental care, alternative medicine treatments, clinical trials, and infertility treatments.

The other category, involving providers outside the insurer's network, would seem more cut-and-dried. But "these disputes can raise extremely serious medical issues," Sara Rosenbaum, JD, professor of health law and policy at the George Washington University School of Public Health, wrote in an accompanying commentary. "For example, [in one case] a health plan member was left permanently paralyzed when the health plan's medical director refused to approve out-of-network neurologic emergency care."

So is the dispute system working? It's hard to say, says Studdert. The fact that patients win about half of all appeals "may tell us that the appeals system works well, that it's not just a rubber stamp process. On the other hand, it raises the [concern] that the initial decision makers are getting it wrong that often. Our suspicion is that one of the reasons they may get it wrong is that it's really hard to make the decision in some of these cases -- it's just not clear."

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