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Health Care Reform:

Health Insurance & Affordable Care Act

Patients Take on HMOs -- and Win

Appeals to HMOs Successful Half the Time

continued...

Clearly, not all disputes are actionable, so trod carefully before considering an appeal. "There are many factors that must get weighed. When a treatment is futile, when it is not going to maintain you or restore you, it no longer has any value. It's not black and white, but that's why you need people with good medical judgment making those kinds of decisions."

She says she believes the evidence suggests that the internal review system is working well, citing the fact that there were 4 million subscribers at the two HMOs over the course of the study and they generated a small number of appeals. "It is rarely used, most of the cases are readily resolvable, and there are a few cases where it turned out to be a really good thing that the process was there," she tells WebMD.

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