-Caveat Lector-
There is a definite conflict of interest in these cases as there are in pharmaceutical
companies payments to physicians that should be put a stop to. Basing care on what is
medically necessary as determined by physicians who are unencumbered by economic ties
and incentives should be the only way to go, never should it be based on economic
means when someone's health is at stake. It surprises me that people don't see the
obvious conflict this creates.
On Mon, 18 June 2001, Bill Richer wrote:
>
> -Caveat Lector-
>
> WJPBR Email News List [EMAIL PROTECTED]
> Peace at any cost is a Prelude to War!
>
>
> Patients fighting HMOs' denial of claims, and many are winning
> MICHELE CHANDLER
> [EMAIL PROTECTED]
>
> Dawn Ripley never had a problem with her health insurance plan -- until her
> daughter, Anna, came along last year.
>
> ``I noticed her head seemed misshapened, it seemed like she had more face on
> one side than the other,'' said Ripley, who lives in Weston. After several
> months of therapy, a physician determined that the infant's condition could
> be corrected with a special $3,000 helmet.
>
> Ripley's insurance company denied the request, deeming Anna's condition
> cosmetic, not medical.
>
> She paid out of pocket for the device. But Ripley also began a fight to the
> finish with her insurer -- which ultimately paid.
>
> Amid a national debate over patients' rights and growing frustration with
> managed care -- eight of every 10 Florida residents are in those plans --
> thousands of Floridians each year are challenging the decisions of their
> HMOs, and many are winning. Statewide figures are not available, but at one
> healthcare insurer -- Health Options, one of the state's largest -- 4,981
> Florida patients lodged complaints last year, and 675 entered the plan's
> formal grievance process.
>
> A patients' bill of rights that will be debated in Congress this week would
> give HMO members new rights to sue if they are denied needed care. The two
> proposals the Senate will debate differ mainly over how patients can sue
> managed-care companies and whether the companies' liability should be limited.
>
> But in many cases, there are existing alternatives.
>
> By state law, consumers at odds with an HMO's decision are entitled to appeal
> through their health plan's grievance process -- and thousands do just that
> every year. If the decision still doesn't go the patient's way, the consumer
> can take the case to the Statewide Provider and Subscriber Assistance
> Program, a state government-run panel of state officials, physicians and
> consumers that will make a binding decision.
>
> Overall, 21 percent of the 177 cases taken to the panel last year were
> decided in favor of patients, according to the Agency for Health Care
> Administration, which runs the program. An additional 29 percent of the cases
> were settled in favor of the consumer before the panel's review.
>
> The top disputes: repayment for emergency care, treatment by non-network
> medical providers, and clashes over benefits and what should be deemed
> medical necessities.
>
> Among the cases overturned by the state panel: It ordered an HMO to cover
> surgery needed by a patient who received facial injuries while cleaning his
> shotgun. The HMO had said it would not cover some of the surgery on the
> grounds that it was cosmetic; the HMO's doctors insisted the surgery was
> needed to restore function.
>
> Although Ripley's case was resolved without going before the state panel,
> Ripley's health plan also initially deemed Anna's condition cosmetic and
> would not pay for the head brace to correct it. That prompted Ripley to
> embark on a mission to prove that the device was a medically necessary
> treatment.
>
> She linked up with an Internet support group -- www.caps2000.org -- for
> families of children with the same problem. At night, she scoured medical
> encyclopedias online. She contacted the manufacturer of the head brace, who
> told her that her insurance company and others had paid for the device. She
> wrote to her elected officials. She got letters of support from the child's
> doctors.
>
> The health plan, which was offered by her husband John's employer, turned her
> down.
>
> She appealed a second time, as the health plan's grievance procedure allowed.
> And she contacted her husband's employer, United Parcel Service, hoping the
> company would help with her appeal.
>
> After several months, she won the appeal -- with the health plan agreeing the
> device was medically necessary. Payment for the device was approved a few
> weeks later and the Ripleys were reimbursed.
>
> The lesson? Persistence can pay off.
>
> ``That's how hard you have to fight them,'' Ripley said. ``Don't quit. Keep
> going.''
>
> Beth Gabrini, an information specialist with the Florida Department of Elder
> Affairs' program known as SHINE, or Serving the Health Insurance Needs of
> Elders, said some denials stem from a simple error -- an improper billing
> code entered by a medical provider. Those codes are used by insurers to match
> a medical procedure with a payment.
>
> ``Usually the error might be made on the part of the doctor's office when
> they submitted your claim,'' Gabrini said. Call the physician's office, she
> said, and ask people there to make sure the code submitted is correct. ``They
> are pretty interested in getting their money, too, and they usually are
> pretty willing to see if an error has been made.''
>
> If that's not the case, Florida HMOs are required by law to have a grievance
> process in place for patients who don't agree with their insurer's decision
> and want to appeal.
>
> And enlist your doctor's help. When appealing an insurance denial, your
> physician can be your most powerful ally, several consumer experts said.
>
> ``If the primary care physician and specialist are backing the patient,
> there's a 99 percent chance the case will be approved,'' said Gihan ElGindy,
> executive director of the Transcultural Educational Center, a health and
> education consulting firm in Virginia that assists people with insurance
> issues.
>
> The appeals process doesn't guarantee a win.
>
> In one case last year that went to the state panel, an HMO member with
> narcolepsy -- uncontrollable sleepiness -- requested a prescription
> medication not on the health plan's list of approved drugs. The health plan
> denied the request, a decision the statewide panel upheld.
>
> The panel also supported another HMO's decision not to pay for treatment by
> an out-of-network neurosurgeon for a health plan member with a brain tumor,
> saying the HMO network contained qualified medical specialists.
>
> Then there's Donna Young, 36, of Fort Lauderdale, who signed up for an HMO
> after she said a sales representative told her the health plan would cover
> the costly medication she needed for severe pain caused by multiple sclerosis.
>
> But the HMO did not cover the medication.
>
> Young filed a grievance, but the health plan denied the medication request.
>
>
>
>
> *COPYRIGHT NOTICE** In accordance with Title 17 U. S. C. Section 107,
> any copyrighted work in this message is distributed under fair use
> without profit or payment to those who have expressed a prior interest
> in receiving the included information for nonprofit research and educational
> purposes only.[Ref. http://www.law.cornell.edu/uscode/17/107.shtml ]
>
> Want to be on our lists? Write at [EMAIL PROTECTED] for a menu of our lists!
>
> <A HREF="http://www.ctrl.org/";>www.ctrl.org</A>
> DECLARATION & DISCLAIMER
> ==========
> CTRL is a discussion & informational exchange list. Proselytizing propagandic
> screeds are unwelcomed. Substance�not soap-boxing�please! These are
> sordid matters and 'conspiracy theory'�with its many half-truths, mis-
> directions and outright frauds�is used politically by different groups with
> major and minor effects spread throughout the spectrum of time and thought.
> That being said, CTRLgives no endorsement to the validity of posts, and
> always suggests to readers; be wary of what you read. CTRL gives no
> credence to Holocaust denial and nazi's need not apply.
>
> Let us please be civil and as always, Caveat Lector.
> ========================================================================
> Archives Available at:
> http://peach.ease.lsoft.com/archives/ctrl.html
> <A HREF="http://peach.ease.lsoft.com/archives/ctrl.html";>Archives of
> [EMAIL PROTECTED]</A>
>
> http:[EMAIL PROTECTED]/
> <A HREF="http:[EMAIL PROTECTED]/";>ctrl</A>
> ========================================================================
> To subscribe to Conspiracy Theory Research List[CTRL] send email:
> SUBSCRIBE CTRL [to:] [EMAIL PROTECTED]
>
> To UNsubscribe to Conspiracy Theory Research List[CTRL] send email:
> SIGNOFF CTRL [to:] [EMAIL PROTECTED]
>
> Om
"Welcome to the desert of the real." Morpheus, in The Matrix
"My God it's full of stars!" Dave Bowman, in 2001: A Space
Odyssey
Find the best deals on the web at AltaVista Shopping!
http://www.shopping.altavista.com
<A HREF="http://www.ctrl.org/";>www.ctrl.org</A>
DECLARATION & DISCLAIMER
==========
CTRL is a discussion & informational exchange list. Proselytizing propagandic
screeds are unwelcomed. Substance�not soap-boxing�please! These are
sordid matters and 'conspiracy theory'�with its many half-truths, mis-
directions and outright frauds�is used politically by different groups with
major and minor effects spread throughout the spectrum of time and thought.
That being said, CTRLgives no endorsement to the validity of posts, and
always suggests to readers; be wary of what you read. CTRL gives no
credence to Holocaust denial and nazi's need not apply.
Let us please be civil and as always, Caveat Lector.
========================================================================
Archives Available at:
http://peach.ease.lsoft.com/archives/ctrl.html
<A HREF="http://peach.ease.lsoft.com/archives/ctrl.html";>Archives of
[EMAIL PROTECTED]</A>
http:[EMAIL PROTECTED]/
<A HREF="http:[EMAIL PROTECTED]/";>ctrl</A>
========================================================================
To subscribe to Conspiracy Theory Research List[CTRL] send email:
SUBSCRIBE CTRL [to:] [EMAIL PROTECTED]
To UNsubscribe to Conspiracy Theory Research List[CTRL] send email:
SIGNOFF CTRL [to:] [EMAIL PROTECTED]
Om
