HMO coverage is designed to control unnecessary costs while providing a high level of care with low out-of-pocket costs to the patient. The concept is to give incentives to the medical providers that encourage them to keep you well and to treat your illnesses quickly, efficiently and expertly. Unfortunately, problems occur within the system and patients don't know how best to resolve them. Some people have difficulty communicating with their doctors or the doctor's office and tend to "suffer in silence". Others don't know where to turn for guidance and misunderstand their treatment or their coverage. Each problem, like each person, is different and requires specific solutions. Knowing this, here are some hints to help resolve some common problems:

Using your health insurance agent's services: Health insurance agents deal with HMO's and other health plans professionally. It is their job to know the type of coverage you bought from them and how the plan works. The agent knows who to contact within the company to get the service you need. If you have a health insurance agent, make a call to him or her whenever you are having difficulty with the HMO. The majority of problems with your HMO will be quickly resolved by your agent. If your agent cannot resolve the problem, he or she will tell you why and what they recommend. If you have coverage through your employer, you will need to talk to your Human Resources department to find out if you can contact the agent for the company. If there is no agent, unfortunately you are on your own and will have to deal directly with the HMO.

Know your Primary Care Physician: It is always best to choose your Primary Care Physician based upon recommendations of others. Even then, if you have not met your Primary Care Physician, arrange for an annual physical. This is usually covered 100% by the HMO. At the time of your physical, ask the doctor any questions you have about your present and future treatment, and try to determine if you are compatible (not everyone gets along with everyone else). If you do not feel comfortable with the doctor, you can change your Primary Care Physician to another. Be sure to visit that doctor as well and make sure that you feel confident in that person.

If you live in a rural area or one where there are not very many choices of Primary Care Physicians, you might see if another doctor within the medical group would be more compatible. Again, visit the doctor and express your opinions and concerns and feel free to ask questions until you are comfortable with the care you will be given. If you have confidence in your Primary Care Physician, obtaining medical care will be a lot easier.

Communicate with your Doctor: If a problem has come up that you do not feel has been resolved, call your Primary Care Physician and discuss it with him/her. Communication is the best method of problem resolution. If you have not communicated the problem, the doctor can't possibly remedy the situation. By communicating with the doctor, you are doing both of you a service. Ask questions until you are satisfied with the information and decisions being made.

Being Assertive: If you find that you cannot come to an agreement with your Primary Care Physician, ask for a second opinion from another primary care doctor or a specialist, and politely insist upon receiving it. There may be procedures already in place to obtain second opinions or specialist opinions and if that is the case, your Primary Care Physician should assist you to obtain them. If necessary, call your HMO customer service and have them arrange for a specialist or second opinion. Pay attention to your own feelings regarding your medical treatment and don't be afraid to insist upon answers from those who are providing you care. No one should ever belittle your feelings or question the validity of your concerns. Keep asking questions and seeking information until you are satisfied with your care.

Seeing Specialists: Every condition has a specialist somewhere but not every condition requires a specialist. Ordinarily, your Primary Care Physician will refer you to a specialist whenever it is necessary. The vast majority of Primary Care Physicians will not attempt to treat a condition for which they are unqualified. Most HMO contracted medical groups have specialists and since they are all contracted together, there is no incentive to withhold a referral to a specialist where it is needed.

Problems arise when there is a need for sophisticated diagnostic tests or highly specialized treatment outside the medical group. In these cases, the medical group may be responsible for all or part of the cost and will require a meeting to determine whether or not the referral or tests are really necessary. When this happens, a committee within the medical group looks at all the information and makes a decision to refer or not. Since not all HMOs are structured the same way, there are many variations of this way to refer care. If you feel that the referral is not being made when it should, then you can contact the customer service department of your HMO and ask for an outside determination.

Emergencies: New laws categorize an emergency using the "prudent layperson" standard. If a reasonable person would have sought emergency care, then the HMO has to recognize it as an emergency and cover it accordingly.

Virtually all HMOs require that you notify them when you have obtained emergency care (such as a hospitalization). The usual time frame is within 48 hours (when practical). If you are involved in an emergency situation, seek care immediately. If there is time, and the information is readily available, try to go to a facility which is contracted with your HMO. This will prevent a disruption of your care later on, when you might be required to be moved to a contracted hospital.

It's a good idea to look up the hospitals who are on your HMO when you go on the plan so that you don't have to worry about it if something unforeseen happens. In any emergency, use your common sense. If you need help, get it first, then worry about the coverage later. If you've acted reasonably, the chances are excellent that you will have coverage. If you don't, you'll at least have preserved your health.

The most important thing is your health: Many people are under the impression that if their HMO doesn't cover a procedure or referral that they can't have it. They think that if their HMO has denied a request for a test or referral that it isn't available to them. That is not the case! Anyone at any time can see any doctor or obtain any test they want; they just might have to pay for it themselves.

If you are in a position where you believe you need to have a particular test or to see a particular specialist in order to preserve your health, and your HMO has denied coverage for it; ask yourself this question: "How much is my health or life worth?" Is your health worth the cost of a blood test? an MRI? A CAT scan? A specialist work up and examination? Remember that if you have used up all of your options within the HMO and you still feel you need the treatment or diagnosis; arrange for it yourself. Either you are right, or you are wrong. If you are wrong, you've invested in the cost of the procedure to obtain peace of mind. If you are right, the treatment can then be obtained through your HMO, and probably the cost of the outside diagnosis as well. Remember, it is your body, and you are responsible for your own medical care. You choose your own insurance coverage, and you can also choose how you use it.

HMO stands for “Health Maintenance Organization”. It was designed to cover not only illnesses, but preventative care such as annual physicals and immunizations that were usually not covered by “regular insurance”. While there are many variations on the way doctors and medical providers are paid under HMOs; the usual practice is for the health plan to pay a fixed amount to a doctor or medical group for each person who chooses them. The doctor or medical group then agrees to provide all the needed medical care for that person for the amount being paid. The theory is that only a certain number of people will become sick and need their services. Most HMO providers take out special insurance to cover them in the event that more people utilize their services than anticipated. 

If a patient needs to have services that cannot be provided within the medical group, the medical group usually has some financial responsibility to pay for the services obtained outside the medical group. This may take some time to arrange since the medical group will have meetings in which the necessity for the treatment is discussed and agreed upon. This is often the reason for delays when there are unusual patient needs. 

HMOs “manage care” of patients to make sure that there is no wasteful medical procedures; but it also makes sure that necessary care is obtained and encourages preventative procedures for both healthy patients and those with chronic diseases like diabetes. More than 80% of Americans covered this way, have expressed satisfaction with their HMO.

The key to obtaining services within an HMO is knowing your primary care physician (PCP). All services must be accessed through your PCP unless your plan has special rules about being able to go to other doctors. New laws now allow women to go directly to their OB / gyn doctor for annual checkups. Some plans allow patients to go to specialists directly so long as they are within the same medical group as their PCP. 

If your PCP is not available in the time you need, some plans allow you to see a substitute doctor in the same medical group. Your PCP can also recommend a substitute doctor who may be more readily available. If you are having difficulty seeing your PCP, you can call your HMO customer service and tell them about it, or you can ask to change your PCP. 

Some HMOs are “staff models”, which means that they hire and pay salaries to their doctors and own their own hospitals. These HMOs usually allow you to see any doctor at any time within their facilities. 

A good way to decide which PCP you want to use is to go see him or her for your annual physical. Take a list of questions with you and see if the physician is someone you can have confidence in. 

Always communicate with your family how you want to be treated and authorize someone to speak on your behalf if you are ill or having surgery. Your insurance agent is always available to help you with any problems you may encounter with your HMO.

Your first call when there is a disagreement over services you feel are medically necessary to you or a family member, should be to your insurance agent. If you do not have a personal insurance agent (like when you have coverage from your employer) there may be an agent for your employer who can assist you. Check with your human resources department to find this out. The insurance agent has a relationship with the HMO and knows how to resolve most problems. 

If you do not have access to an insurance agent, you must call the HMO directly and ask for the customer service department. You must be aggressive in trying to resolve the problem and it may take several calls. Obtain the name and extension of the first person you tell your story to, so that there will be continuity over a period of time and you will not be starting over every time you call. Record pertinent information that is given to you, the date and time you called. Usually, the problem can be resolved. 

If you feel you need services that are being denied and that your health is at risk obtain the care elsewhere on your own and continue to inform the HMO of the necessity of your actions in order to seek reimbursement later for the expense. NEVER DELAY NEEDED CARE!

Because the HMO medical group is usually financially responsible for extraordinary expenses, such as referrals to specialists outside the medical group or diagnostic tests which are not available in the HMO medical group; the process may be lengthy. The medical group’s review board must meet within their scheduled time period and they must determine the medical necessity for the referral. Sometimes the diagnostic test or referral may require approval of the health plan as well. These procedures can cause a delay in obtaining treatment or tests and can be frustrating to the patient. 

If the delay is unreasonable, you can call the health plan directly to determine when or if the referral will take place, or you can have your insurance agent make the inquiry for you. In most cases, however, any delay is minimal and the welfare of the patient comes first. 

If you are ever in an emergency situation, seek medical care wherever it is available. All HMOs allow for emergency treatment outside of their listed providers. (But do obtain authorization as soon as you are able.) If you ever feel that your health is in jeopardy and you cannot resolve the problem with either your PCP or HMO, you may always obtain the treatment on your own and then seek to recover the cost from the HMO later.