If the person reviewing your letter feels you are making a good case for your state agency or a potential lawsuit, the HMO will think twice about continuing to deny the requested medical care. If such letters find their way to lawyers for the HMO, and the lawyers feel that the HMO is threatened by its current position, they will advise the HMO to change it.
Properly prepared letters are a very valuable tool for getting HMOs to provide medical care they do not want to provide. Bearing these thoughts in mind, there are four points that are particularly important to make in letters to your HMO.
- A review of the history of your condition, the medical steps that have been taken, and their results to date. Your review should be as specific as possible, including dates. The last item in this review should be your request for the medical services that are being denied by your HMO. Write this review in a manner that makes clear how your situation has progressed and why it is necessary that the services you are requesting be provided. Be sure to include a statement that your health is being permanently injured by your HMO’s refusal to provide you with further medical care.
- The opinion of a physician that you require the medical services you are being denied. It may be necessary for you to spend your own money to obtain the support of an outside physician for this purpose, but if your condition is serious, you have no other choice. If possible, a letter of opinion from the outside physician should be included. There is nothing more influential than such a letter in these circumstances, especially if the physician’s reasons for his or her opinion are carefully explained.
- A request that your HMO provide to you, in writing, its specific reasons for not providing you with the requested medical services. Include a request that the names of the physicians whose opinions are being relied upon by the HMO be disclosed to you. Although this will frequently not occur, it is important to make such a request since your HMO may realize when you do that it is unable to support its position with medical authority. Physicians employed by HMOs, and indeed all physicians, provide verbal opinions far more easily than written ones.
- Advise your HMO that if the medical care you are requesting is not provided, legal action will be taken.