A letter from you sent in this fashion is a wake-up call when an HMO receives it. It knows, because you have taken the time and spent the money to have the letter certified, that you are taking the matter very seriously. It also knows, since someone in the HMO must sign the receipt, that you have acquired proof that you have given the HMO the information in the letter.
In your letter, summarize your condition and be very specific about the dates you have seen your general physician, the tests you have undergone, the course of action your general physician has prescribed, and all other relevant matters. If you have consulted an outside physician, mention that physician.
If your HMO has not provided you with a reason for denying the medical treatment you are seeking, request that it do so. Letters like this should be typed, carefully written, and concise. Try not to criticize your general physician any more than necessary. Even though your general physician works for the HMO, he or she may be on your side in the matter, and if so, you want to keep him or her there.
The purpose of writing letters to HMOs when there are disputes is to get their business interests working for you. An HMO’s business interests are making as much money as possible and providing as little medical care as possible without getting in trouble with state authorities and without being forced to defend expensive lawsuits. Such letters take the wiggle room out of the HMO.
It cannot say that you did not specifically request particular medical care when a letter from you clearly confirms that you did request it. Explanations such as, “We thought we had agreed on a wait-and-see approach to her condition” or “He did not explain his entire history when we made our determination” simply do not fly when properly written letters confirm that the situation was otherwise.
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