He referred her to a urologic surgeon affiliated with the HMO. The surgeon diagnosed the girl with a Wilms tumor , a rare cancer.
An 88-year-old Sacramento, California, woman developed kidney failure. The drugs and dietary therapy recommended by her HMO doctor proved ineffective. She needed dialysis. Her doctor believed that dialysis might extend her life. He also knew that dialysis would cost the HMO $40,000 a year.
Many HMOs prohibit doctors from telling patients that the best doctor or best treatment might not be provided by the patients plan. Find out what constitutes the best possible care for your condition...and who is best at delivering it If HMO doctors cant provide it, fight to get it outside the plan.
HMO Horror Stories. HMOs are a mixed bag. They excel at disease prevention and screening. But because HMO doctors are often pressured to contain costs, H MO members who fall ill dont always get the best possible care. Here are some real- life HMO horror stories...and how to avoid being similarly victimized.
The surgery proceeded anyway, and the girl was cured. The HMO refused to pay for the $50,000 operation, arguing that the girls parents had violated their HMO contract by going outside the plan. Lesson: Dont expect your HMO to refer you to the best specialists.
Still, the doctor refuse d. Under his HMO contract, the doctor had to pay directly for every test and specialist referral he ordered. Finally, at the mans insistence, the doctor performed more tests ...and ultimately determined that he was suffering from colon cancer. By this time, however, the cancer had spread.
For instance, the birth guidelines for most HMOs now state that a normal delivery requires no more than a 24-hour hospital stay, and a Caesarean section requires no more than 48 hours. Be aware that these guidelines are not regarded as discretionary guidelines to be overridden if a physician feels they are not in the patient’s interest but are actually strictly applied.
A complaint frequently cited by HMO patients is that information given out by HMO representatives is not always reliable. For instance, a patient may call the HMO to inquire whether a certain procedure is covered, or how soon you must notify the HMO after an emergency room visit, and the answer may not be correct—a nuisance for the patient, who must end up paying out of pocket or spending time and energy appealing the HMO’s denial.
Any time you go to the emergency room, you’ll have to call your primary care doctor (or another HMO number) within a certain amount of time, usually 24 hours. TIP: Carefully investigate how the HMO defines emergency.
2. LACK OF COVERAGE FOR CERTAIN PROCEDURES.
It’s important to have a primary care doctor whom you trust. You will rely on this physician not only for care for you and your family, but also for referrals to specialists. Carefully investigate the doctors you are considering choosing as your gatekeeper .
Many HMOs now pay member physicians by capitation, a payment method in which the doctor receives a monthly payment "per capita"—i.e., by a patient head count. In other words, for every patient that is signed up with a certain doctor as a primary care physician, the physician receives a monthly payment.
With a risk pool, primary care physicians get a sum in addition to the withhold with which to pay for specialists and other out-of-the-ordinary care. Whatever part of the risk pools is not used for patient referrals and care goes to the physician.
Many different things have been tried, but none have put a cease to the exorbitant costs, which most believe to be the main problem. Out of everything tried, the most recent and popular system is known as managed care. Managed care is the most common form of health insurance in the United States, and provides more
relationship of an HMO and its physician member is to help provide a wider range health care for its patients and a wide area of services available for its physician members. A patient must choose a primary care physician from a list of providers. The relationship with the physician provided from the HMO is in a contract that is to deliver services to their patients for a fee. There can also be a group plan which is a HMOs contract with a group of physicians to deliver services. The HMO organization compared
Birth of Health Insurance Health insurance started in the early twentieth century when the working class of America faced the problem of sickness