Although the techniques previously mentioned for further testing work a good deal of the time, there are situations when a member of an HMO cannot obtain the treatment he or she feels is necessary, no matter what informal steps are taken. When that occurs, you will need to resort to formal steps to provide you with the best chance for obtaining the care you need.
Even if you have selected your HMO carefully and done everything correctly to establish a good relationship with it, you may sometimes have disputes. Disputes will always boil down to one thing—money. Sometimes you may want a second opinion or a particular treatment that your HMO does not want to provide. You may want drugs or other items that your HMO contends are unnecessary.
Unless what you are seeking is clearly excluded from coverage in your provider agreement, in which case you are simply out of luck, the matter is always debatable. The first line of attack is an appeal to your general physician. General physicians are often caught between a rock and a hard place on such matters, but with a little diplomacy, they may come around to your position. After that, there is a review procedure set forth in your provider agreement. Usually, the review involves at least one appeal to a reviewing authority within the HMO, and thereafter, a reviewing authority in your state government.
Disputes with an HMO arise when you are unable to obtain the medical care you need by informal means. Unless there is a provision in your HMO contract excluding the particular medical care from coverage, the issue between you and the HMO may take several forms. Sometimes HMOs contend that the medical care you are seeking is unnecessary. At other times, HMOs contend that another form of medical care (invariably less expensive) is sufficient.
HMOs also claim at times that the medical care you are seeking for your particular condition is not recommended or is experimental. When your HMO’s reason for denying you the medical care you are seeking depends upon medical judgment, your HMO will have at its disposal physicians that will assist it.
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